


LIBRARY OF CONGRESS: 

©fjap Capi^M i/c- 



UNITED STATES OF AMERICA. 






DISEASES 



Nose and Throat 



A Text-Book for Students and 
Practitioners. 



HORACE F. "IVINS, M.D., 



LECTURER ON LARYNGOLOGY AND OTOLOGY IN THE HAHNEMANN MEDICAL COLLEGE OF PHILADELPHIA; 

LARYNGOLOGICAL EDITOR OF "THE JOURNAL OF OPHTHALMOLOGY, OTOLOGY, AND LARYNGOLOGY"; 

MEMBER OF THE AMERICAN INSTITUTE OF HOMOEOPATHY, OF THE HOMOEOPATHIC 

MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA, ETC. 



WITH ONE HUNDRED AND TWENTY-NINE ILLUSTRATIONS, 
INCLUDING EIGHTEEN COLORED FIGURES. 




PHILADELPHIA AND LONDON : 

THE F. A. DAYIS CO., PUBLISHERS. 

1893. 






■ [J/ 






Entered according to Act of Congress, in the year 1893, by 

THE F. A. DAVIS CO. 

In the Office of the Librarian of Congress at Washington. 

All rights reserved. 



Tha Medical Bulletin Printing House, 

No. 1916 Cherry Street, 

Philadelphia. 



A 



CHARLES MONROE THOMAS, M.D. 

The Author's Teachek, Preceptor, Friend, 
THIS WORK IS 

GRATEFULLY AND AFFECTIONATELY 
DEDICATED. 



PREFACE. 



Although the following pages are especially intended for 
practical aids to the advanced medical student and general 
practitioner, it is hoped that they will also prove of value to the 
specialist in affections of the nose and throat. It was intended, 
at first, to treat each division exhaustively; but, when the 
material was, collected, it was seen that the book would be too 
unwieldy for the student and not sufficiently concise for the 
general practitioner. Only sufficient anatomy and physiology 
of the nose and throat have been given to render clear the 
remaining text. 

In preparing the therapeutic indications it has been my 
endeavor to present a few of the remedies which are character- 
istic and reliable ; it is, however, not always easy to separate 
the true from the spurious. Where possible, I have tested the 
various symptoms recorded, and, finding most of them reliable, 
have allowed them to stand upon their own merits. Those 
remedies which have disappointed, where I have been taught 
to expect much, have been divided into two classes : First, those 
which have failed in a few instances, but have not been 
expunged, as failure may have been due to the fact that the 
remedy was not applied carefully enough. Second, those which, 
although long recommended, I have never found to act well, 
even after many trials of the various potencies and preparations ; 
the latter have been mentioned with the natural comment. 
Another class of symptoms deserves especial reference, namely, 
those that have repeatedly proved curative from a clinical stand- 
point; where, if the symptom stand out boldly from all of its 

(v) 



VI PREFACE. 

class, I have usually noted it as clinical ; but if interwoven with 
others, the clinical aspect has not been separately stated. 

Even with this intended care in the selection of the thera- 
peutic feature, it will be found far from accurate. In order to 
hasten its revision, I would invite criticism and suggestions, for 
it is only in this way that we can hope to establish the true 
merits of the curative sphere of drugs where it is impossible to 
produce, upon the healthy, such symptoms as are often found in 
the diseased. It is unfortunate that the instruments of pre- 
cision — the ophthalmoscope, the rhinoscope, the laryngoscope, 
etc. — were not in existence when Hahnemann and his early 
followers made most of our best provings. 

No attempt has been made to give all of the symptoms of 
any one internal remedy as indicating it in a given case, but the 
chief points have been mentioned as referable to the local symp- 
toms mainly, or those bearing directly upon the condition pres- 
ent. Occasionally some reference is made to general charac- 
teristic drug symptoms where the prescription is to be based 
chiefly upon these. In prescribing for any given case there are 
many conditions to be borne in mind besides the special patho- 
logical change which most attracts attention, namely, the various 
reflexes are to be noted ; the collateral symptoms of the patient 
are to be investigated ; the special temperament is to be con- 
sidered ; but, above all, the previous pathological changes, the 
ancestry, and the mental peculiarities are to be carefully 
reviewed. Thus, while remedies and symptoms are given, it 
will be seen that they form but the sign-posts to direct atten- 
tion. Each prescription must be worked out on the broad 
lines of the nearest similar, if possible ; if not, the resort to 
alternation and the empirical prescription are not to be neglected 
at the expense of the patient. 



PREFACE. Y11 

The arrangement and treatment of some of the subjects do 
not correspond with those of other text-books. These differ- 
ences are the result of various tests, practically applied, during 
my twelve years' lectures. For more ready reference a special 
heading, " Remedies for the Vocal Defects of Singers," has been 
introduced. 

With few exceptions (cuts of instruments excluded), the 
illustrations are from my original photographs, drawings, or oil- 
sketches, and any short-comings in this direction must be attrib- 
uted to a desire for original work. In order to preserve the 
accuracy of the anatomical photographs, I have prepared ex- 
planatory keys to accompany the engravings, so that the latter 
need not be marred. After repeated trials it was found that 
the best results were obtained by photographing most of the 
dissections about four-fifths natural size. 

At the beginning of Part III (page 320) will be found the 
reproduction of a photograph kindly sent me by Signor Manuel 
Garcia, the inventor of the laryngoscope. 

In concluding, I wish to express my hearty thanks to Dr. 
Charles Monroe Thomas for many valuable suggestions in the 
manuscript ; to Dr. R. B. Weaver for his kindness in making 
the beautiful dissections from which the anatomical photographs 
were taken ; to my wife for much aid in preparing for the press, 
as well as for the oil-paintings reproduced on pages 350 and 
459 ; and to those who have aided by direct information, and 
to whom credit has been given in the body of the work. 

Horace F. Ivins. 

1319 Arch Street, Philadelphia, 
February, 1893. 



TABLE OF CONTENTS. 



PART I. 

THE NOSE AND ITS DISEASES. 
CHAPTER I. 



Anatomy of the Nose, 3 

Accessory Cavities, 5 — Physiology of the Nose, 9. 

CHAPTER II. 
Rhinoscopy, Examination of the Nasal Passages, ... 14 
Illumination, 15 — Anterior Rhinoscopy, 18 — Posterior Rhi- 
noscopy, 20. 

CHAPTER III. 
•Catarrhal Diseases of the Nasal Cavities, .... 26 
Acute Nasal Catarrh, 26 — Rhinorrhoea, 33 — Chronic Nasal 
Catarrh, 34 — Hypertrophic Rhinitis, 39 — Atx-ophic Nasal 
Catarrh, 47. 

CHAPTER IV. 

Various Diseases of the Nasal Cavities, 57 

Rhino-scleroma, 57 — Chronic Blennorrhoea of the Upper Air- 
Passages, 58 — Acute Purulent Rhinitis of Children, 59 — 
Chronic Purulent Rhinitis of Children, 61 — Phlegmonous 
Rhinitis, 62 — Glanders, 63 — Croupous, or Pseudomem- 
branous, Rhinitis, 65 — Primary Diphtheria of the Nose, 67 
— Parasitic Affections of the Nose, 68. 

CHAPTER V. 

Ulcerative Diseases of the Nasal Passages, . . . .71 
S} r philis of the Nose, 71 — Lupus of the Nose, 76 — Scrofula, 
77 — Tuberculosis, 79. 

CHAPTER VI. 
Pollen Catarrh — Hay Fever — Summer Catarrh — Periodical 

Vasomotor Rhinitis, 82 

(viii) 






TABLE OF CONTENTS. IX 

CHAPTER VII. 

Neuroses op the Nose, 91 

Anaesthesia, Hyperesthesia, 91 — Neuralgia, Reflex Conditions, 
92 — Anosmia, 94 — Hyperosmia, 95 — Parosmia, 96. 

CHAPTER VIII. 

Various Conditions, 98 

Epistaxis, 98 — Foreign Bodies in the Nasal Passages, 104 — 
Rhinoliths and Calcification of the Mucous Membrane of 
the Nose, 108. 

CHAPTER IX. 

Nasal Tumors, 109 

Benign Growths, 109 — Malignant Tumors, 126. 

CHAPTER X. 

Defects in Bones and Cartilages, 130 

Dislocation of the Bones and Cartilages, 130 — Fracture of the 
Nasal Bones, 131 — Deviation of the Septum, 132 — Atrophy 
of the Septum, Congenital Malformations, 136. 

CHAPTER XL 

Diseases op the Accessory Cavities, 138 

Antra of Highmore, 138 — Frontal Sinuses, 142 — Ethmoid 
Cells, 145— Sphenoid Cells, 146. 



PART II. 
THE PHARYNX AND ITS DISEASES. 

CHAPTER XII. 

Anatomy and Physiology op the Palate and Pharynx, . . 151 

CHAPTER XIII. 

Examination of the Pharynx — Pharyngoscopy, . . . .160 

CHAPTER XIV. 
Pharyngeal Diseases, 163 

Acute Catarrhal Pharyngitis, 163 — Subacute Catarrhal Pharyn- 
gitis, 169 — Angina Ulcerosa, Chronic Catarrhal Pharyngitis, 
170 — Acute Traumatic Pharyngitis, 178 — Acute Follicular 
Pharyngitis, 179 — Chronic Follicular Pharyngitis, 181 — 
Atrophic Pharyngitis, 186. 



X TABLE OF CONTENTS. 

CHAPTER XV. 

Acute Infectious Diseases, 189 

Erysipelas of the Pharynx, 189 — Phlegmonous Pharyngitis, 
191 — Gangrenous Sore Throat, 194. 

CHAPTER XVI. 

Abscess, Ulceration, Parasites, 198 

Post-Pharyngeal Abscess, 198 — Ulceration of the Pharynx, 
200 — Parasitic Diseases of the Pharynx, 201. 

CHAPTER XVII. 

Exudative Pharyngitis, 203 

Herpes, 203 — Acute Membranous Pharyngitis, 205 — Diph- 
theria of the Pharynx and Larynx, 207. 

CHAPTER XVIII. 

Various Conditions, 23T 

Hemorrhages of the Pharynx, 237 — Rheumatic and Gout}' 

Pharyngitis, 238. 

Throat Affections of the Exanthemata, 239 

Measles, Small-Pox, 239 — Scarlet Fever, Tuberculosis of the 
Pharynx, 240. 

CHAPTER XIX. 

Syphilis, Scrofula, Lupus, Leprosy, 245 

Syphilis of the Pharynx, 245 — Scrofulous Pharyngitis, 251 — 
Lupus of the Pharynx, 253 — Leprosjr of the Pharynx, 255. 

CHAPTER XX. 

Tumors and Foreign Bodies, 256 

Tumors of the Pharynx, 256 — Cancer of the Tonsils and 
Palate, 258— Foreign Bodies in the Pharynx, 260. 

CHAPTER XXI. 

Stenosis, Dilatation, Malformation, 264 

Stricture of the Pharynx, 264— Dilatation of the Pharynx, 267 
— Congenital Malformations of the Pharynx, 269. 

CHAPTER XXII. 

Neuroses of the Pharynx, 271 

Sensory Changes, 271 — Motor Changes, 274. 



TABLE OF CONTENTS. XI 

CHAPTER XXIII. 

Tumors of the Naso-Pharynx, 2TT 

Adenoid Vegetations of the Vault of the Pharynx, 277 — Post- 
Nasal Fibroids, 284 — Fibro-Mucous Polypi, 285 — Enchon- 
dromata, Malignant Tumors, 286. 

CHAPTER XXIV. 

Uvular and Tonsillar Diseases, 288 

Uvulitis, Acute Inflammatory CEdema, 288 — Relaxed Uvula, 
289— Tumors of the Uvula, 291— Acute Tonsillitis, 292— 
Acute Follicular Tonsillitis, 299— Enlarged Tonsils, 301— 
Supernumerary Faucial Tonsils, Atrophy of the Tonsils, 
Enlargement of the Lingual Tonsil, 310 — Calculi and Con- 
cretions in the Tonsils, 311 — Diseases of the Valleculse and 
Pyriform Sinuses, 312. 

CHAPTER XXV. 

Catarrh of the Naso-Pharynx, 314 

Acute Naso-Pharyngeal Catarrh, 314 — Chronic Naso-Phaiyn- 
geal Catarrh, 315. 



PART III. 

THE LARYNX AND ITS DISEASES. 

CHAPTER XXVI. 

Anatomy and Physiology of the Larynx, 321 

Vocalization, 337 — Anatomy and Physiology of the Trachea, 
339. 

CHAPTER XXVII. 

The Laryngoscope and Laryngoscopy, 341 

The Laryngeal Image, 348 — Laryngeal Photograph}^, Auto- 
Laryngoscopjr, 354. 

CHAPTER XXVIII. 
Neuroses of the Larynx, 355 

Sensory Changes, 355 — Motor Changes, 356 — Spasmodic Affec- 
tions, 370 — Remedies for the Vocal Defects of Singers, 
383. 



Xll TABLE OF CONTENTS. 

CHAPTER XXIX. 

Inflammatory Affections, 386 

Subacute Laryngitis, 386 — Alcoholic Laryngitis, 390 — Acute 
(Submucous) Laryngitis, 391 — Chronic Catarrhal Laryn- 
gitis, 395. 

CHAPTER XXX. 

Hypertrophy, Atrophy, (Edema, 405 

Subglottic Chronic Laryngitis, Chronic Hypertrophy of the 
Larynx, 405 — Atrophy of the Vocal Bands, Atrophy of the 
Larynx, 407 — Acute (Edema of the Larynx, 408 — Chronic 
(Edema, 413. 

CHAPTER XXXI. 

Abscess, Erysipelas, Lupus, Leprosy, Tuberculosis, . . . 415 
Abscess of the Larynx, 415 — Erysipelas of the Larynx, 416 — 
Lupus of the Larynx, 418 — Leprosy of the Larynx, 421 — 
Laryngeal Tuberculosis, 423. 

CHAPTER XXXII. 

Syphilis and Stenosis, 438 

Syphilis of the Larynx, 438 — Stenosis of the Larynx, 445. 

CHAPTER XXXIII. 

Exudative Diseases, 450 

Croup, 450 — Traumatic Croup, 455. 

CHAPTER XXXIY. 
Laryngeal Tumors, 456 

Benign Neoplasms, 456 — Malignant Tumors, 468. 

CHAPTER XXXV. 
Disease of the Perichondrium and Cartilages, .... 476 

CHAPTER XXXVI. 

Secondary Laryngeal Diseases, 481 

Typhoid and Typhus Fevers, 481 — Measles, 483 — Scarlet 
Fever, Chicken-Pox, 484 — Small-Pox, Whooping-Cough, 
485— Urticaria, 486. 



TABLE OF CONTENTS. Xlll 

CHAPTER XXXVII. 

Various Conditions, 487 

Foreign Bodies in the Larynx, 487 — Wounds of the Larynx, 
490 — Fractures and Dislocations of the Laryngeal Carti- 
lages, 491 — Congenital Deformities of the Larynx, Laiyngo- 
Tracheal Ozaena, 493. 

CHAPTER XXXVIII. 

Diseases of the Trachea, 494 

Acute Tracheitis, 494 — Chronic Tracheitis, Tracheal Syphilis, 
495. 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

Frontispiece. (From a photograph.) 

1. Transverse vertical section through posterior portions of orbits. Looking for- 

ward. With key. (From a photograph.), 2 

2. Vertico-antero-posterior section : septum removed. With key. (From a photo- 

graph.), 4 

3. Spheno-palatine ganglion. (From Sajous.), 8 

4. Kramer's nasal speculum, 14 

5. Author's self-retaining wire speculum, 15 

6. Oval, hard-rubber nasal speculum, 15 

7. Zaufal's speculum, 15 

8. Argand gas-bracket with three arms, 16 

9. Mackenzie's condenser for Argand burner, 17 

10. Photophore, 17 

11. Head-mirror with band and handle, 18 

12. Spectacle-frame, 18 

13. Position for anterior rhinoscopy. (From a photograph.), 19 

14. Rhinoscopic mirror, 21 

15. Fraukel's rhinoscopic mirror, 21 

16. Rhinoscopic mirror in position. (From a photograph.), 22 

17. Posterior rhinoscopic image. (Modified from Sajous. Colored.), ... 24 

18. Finger-guard, 25 

19. Burgess' atomizers, 28 

20. Air-compressor, with two outlets, 29 

21. U-shaped nasal tube, 36 

22. Dessar's nasal cup, 36 

23. Post-nasal syringe, 37 

24. Posterior hypertrophy of middle and inferior turbinated bodies, both sides. 

(From Sajous. Colored.), 42 

25. Author's nasal probe, 44 

26. Sajous' guarded acid applicator, 44 

27. Author's guarded post-nasal acid applicator, 44 

28. Jarvis' snare, as modified by Sajous, 44 

29. Cautery-knife and points, 45 

30. Galvano-cautery handle and snare, 45 

31. Angular forceps, 52 

32. Insufflator, 52 

33. De Villbis' atomizer, 60 

34. Politzer's air-bag, 74 

35. Eustachian catheter, 103 

36. Bellocq's cannula, 103 

37. Gross' curette and hook, 107 

38. Myxomata of the nose. (From a retouched photographic negative.), . . . 110 

39. Sajous' snare, with three tips, 112 

40. Wright's snare, 113 

41. Mackenzie's cog-wheel snare. 114 



(xiv) 



LIST OF ILLUSTRATIONS. XV 

FIG. PAGE 

42. Caugh try's light angular forceps, 115 

43. Nasal saws, 122 

44. Jarvis' transfixing needles, 123 

45. Teets' cutting nasal bone-forceps, 124 

46. Burrs and trephines, . 125 

47. Von Klein's nasal bone-forceps, 126 

48. Melanosarcoma of the nose. (Colored.), 127 

49. Bosworth's clamp, 134 

50. Adams' forceps, 135 

51. Steele's septum-forceps, 135 

52. Transverse vertical section through orbits : looking backward. With key. 

(From a photograph.), 138 

53. Bleyer's tongue-depressor and incandescent lamp, ....... 140 

54. Vertico-antero-posterior section. (From a photograph.), 143 

55. Vertical section through basilar process. (From a photograph.), . . . 150 

56. Normal palate and pharynx, 152 

57. Key to Figure 55, page 150, 154 

58. Antero-postero-vertical section, revealing naso-pharyngo-laryngeal region. With 

key. (From a photograph.), 156 

59. Cohen's hard-rubber tongue-depressor, . . . 161 

60. Hinged, metal tongue-depressor, 161 

61. The American nebulizer, 166 

62. Author's pharyngeal and post-nasal applicator, 173 

63. Whitall, Tatum & Co. 'svaselin atomizer, 187 

64. Curved trocar-cannula, 200 

65. O'Dwyer's intubation apparatus, 228 

66. Primary epithelioma of right tonsil. (From a photograph by Dr. N. W. Fryer.), 259 

67. Separate mucous investment of the palato-glossus muscles, 269 

68. Youthful physiognomy of adenoid vegetations. (From a photograph.), . . 278 

69. Aged physiognomy of confirmed mouth-breathing, 279 

70. Adenoid vegetations and hypertrophy of turbinateds, posteriorly. (From Sajous. 

Colored.), 280 

71. White's palate-retractor, 281 

72. Loewenberg's forceps, 282 

73. Gottstein's curette, 282 

74. Curette finger-tip, . 282 

75. Major's antero-posterior adenotome, . . 283 

76. Inhibitor, ' 283 

77. Enchondroma, actual size. (From a photograph.), . . . . . . 2S6 

78. Sajous' uvula-scissors, . 290 

79. Acute follicular tonsillitis. (Colored.), 300 

80. Mackenzie's tonsillotome, as modified by Mandeville, 305 

81. Author's tonsillotome, - 306 

82. Knight's galvano-cautery snare tonsillotome. 308 

83. Leffert'e bulbed insufflator, 316 

84. Signor Manuel Garcia, inventor of the laryngoscope, 320 

85. Laryngeal frame-work : anterior view. With key. (From a photograph.), . 322 

86. Laryngeal frame-work : posterior view. With key. (From a photograph.), . 322 

87. Left side of larynx. (From a photograph.), 327 

88. Posterior crico-arytenoid muscles. With key. (From a photograph.), . . 32S 

89. Right lateral crico-arytenoid muscle. With key. (From a photograph.), . . 330 

90. Laryngoscope, 341 

91. Laryngeal mirrors. (Natural size.), 342 



XV1 LIST OF ILLUSTRATIONS. 

FIG. 

92. The S. S. White Dental Mfg. Co. 's electric laryngoscope, ^43 

93. Beseler's lime-light apparatus, ' .'344 

94. Laryngoscope in position, [ 345 

95. Reflection of V-shaped figure on a laryngeal mirror, 349 

96. Epiglottis, arched and vertical. (Colored.), . 350 

97. Epiglottis, arched and inclined forward. (Colored.), ...... '350 

98. Epiglottis, angular. (Colored.), .'.'.' \ 350 

99. Epiglottis, omega-shaped. (Colored.), .350 

100. Epiglottis, pointed and depressed, of children. (Colored.), . . . ' 350 

101. Epiglottis, horseshoe-shaped. (Colored.), ! 350 

102. Normal larynx during respiration. With key. (Colored.), ' 351 

103. Normal larynx during phonation. (Colored.), .... 352 

104. Auto-laryngoscope, ' ^ 

105. Freshly dissected larynx, showing cadaveric position of vocal bands. With 

key. (From a photograph.), _ 35 g 

106. Left recurrent paralysis, during attempted phonation, 359 

107. Bilateral thyro-arytenoid paralysis, during vocalization, 360 

10S. Bilateral posterior crico-arytenoid paralysis, during inspiration, . . . .362 

109. Arytenoid paralysis, during vocalization, 363 

110. Author's modification of Mackenzie's laryngeal electrode, 365 

111. Subacute laryngitis. (Colored.), 387 

112. Acute (submucous) laryngitis. (Colored.), , 392 

113. Mackenzie's laryngeal bistoury, ' 393 

114. Laryngeal applicator, ' 4(l0 

115. Laryngeal phthisis, showing pyriform arytenoids and ulceration of left vocal 

band. (Colored.), 42 6 

116. Schrotter's hard-rubber bougies, 446 

117. Web-like stenosis, due to syphilis, 447 

118. Browne's hollow cutting-dilator, .'447 

119. Schrotter's metal bougie, 448 

120. Papillomata following typhoid fever, 457 

121. Papillomata in a boy, 458 

122. Papillomata in an army officer, 45g 

123. Papillomata in an inveterate drinker of alcoholics. (Colored.),. . . . 459 

124. Polypus of right vocal band. (Colored.) .460 

125. Mackenzie's antero-posterior laryngeal forceps, 465 

126. Mackenzie's lateral laryngeal forceps, .466 

127. Schrotter's universal handle with various tips, 466 

12S. Author's modification of Schrotter's laryngeal tube-forceps, 467 

129. Author's case of instruments, § 49$ 



PART I. 



The Nose and its Diseases. 




.—Transverse-Vertical Section through Posterior Portions of Okkits, 
Looking Forward. (From a photograph.) 



Eye. 

Ethmoid cells. 

Antro-nasal opening. 

Antrum of Highmore. 

Inferior turbinate'!. 

Roof of mouth. 




nal cavity. 
Superior meatus. 
Superior turbinated. 
Middle meatus 
Middle turbinated. 
Septum. 

Inferior meatus. 
Hard palate. 



Key to Fig. 1. 



CHAPTER I. 

Anatomy of the Nose. 

The nasal passages may be designated double air-tunnels. 
They begin at the anterior nares (nostrils), pass through a 
highly vascular, nervous, and tortuous region, and terminate in 
the posterior nares (choanse). These tunnels are separated, 
antero-posteriorly and vertically, by the nasal septum, which is 
partially cartilaginous, but chiefly bony. The nasal passages 
are narrow above and quite broad below. The septal walls are 
smooth, but, owing to the presence of the turbinated bodies, 
the external walls are very irregular. Connected with these 
canals are several accessory cavities, which often participate in 
pathological changes similar to those which occur in the nasal 
fossae 

The septum narium is about one-tenth of an inch thick 
anteriorly and one-eighth posteriorly. It is formed above by 
the perpendicular plate of the ethmoid bone, posteriorly by the 
vomer, and anteriorly by the triangular (septal) cartilage. 
These various portions are united at their edges, forming a con- 
tinuous, smooth, inner wall to each canal. There is generally a 
prominence (tubercle of the septum) a little anterior and in- 
ferior to the anterior end of the middle spongy bone. 

The roof of each fossa is about one-fourth of an inch wide, 
and formed by the cribriform plate of the ethmoid, the nasal 
spine of the frontal, the under surface of the body of the sphe- 
noid, and by the nasal bones ; the external walls, composed of 
the palate and superior maxillary bones, slant outward and 
downward ; the floor is formed by the horizontal processes of 
the same bones. 

Two scroll-like bones (the turbinated, concha, or spongy 
bones) project from each lateral surface toward the septum ; the 

(3) 



4 DISEASES OF THE NOSE AND THROAT. 

third, superior, is quite small and descends almost perpendicu- 
larly from the roof (see Fig. 1). The middle is larger than the 
superior, has a decidedly curled edge, and projects well toward 
the middle line. Between these two bones lies the superior 
meatus, into which the posterior ethmoidal cells and sphenoidal 




Fig. 2.— Vertico-antero-posterior Section. Septum Removed, During Section, 
Revealing Left Nasal Region. (From a photograph.) 

sinus open through a small aperature situated posteriorly. 
According to Zuckerkandl (" Anatomie der Nasenhole"), the 
ethmoid cells are occasionally continued into the middle, or eth- 
moidal, turbinated bone. The inferior is the largest of these 
bones, and assumes more nearly a horizontal position. Its 



ANATOMY OF THE NOSE. 5 

lower edge is occasionally deeply notched or cleft. The space 
between the inferior and middle turbinateds is known as the 
middle meatus, into which enter the canals from the frontal sinus 
(the infundibulum), the anterior ethmoidal and the sphenoidal 
cells, and the antrum of Highmore (the latter occasionally by 
two passages). Within the middle meatus is a crescentic open- 
ing, the hiatus semilunaris, the upward and downward con- 
tinuations of which pass into the frontal cells and antrum of 
Highmore, respectively. Below the inferior turbinated is the 



an £ i 4 . o £ 



Vault of pharynx. 
Eustachian orifice. 




Superior turbinated. 
Superior meatus. 
Middle turbinated. 
Middle meatus. 
Inferior turbinated. 
Inferior meatus. 
Hard palate. 



Key to Fig. 2. 

inferior meatus, into which the nasal duct opens by a somewhat 
expanded mouth, provided with a partial valve formed of mucous 
membrane. A fourth bone frequently exists in close relation to 
the upper turbinated ; this, according to Zuckerkandl, is the 
rule at birth, and Voltolini considered it characteristic of the 
negro race. 

As the accessory cavities are in such close relationship to 
the nasal cavities, it is customary to describe these sinuses, or 
pneumatic chambers, in this connection. They lighten the 



b DISEASES OF THE NOSE AND THROAT. 

bones in which they are situated, and are supposed to afford 
increased resonance to the voice. 

The frontal cells, usually wanting in early childhood, are 
two triangular spaces situated just above the nose and inner 
portions of the orbits, between the two tables of the frontal bone 
(see Fig. 2). They are sometimes separated, but more frequently 
a passage exists between them. Their floors are formed by the 
roofs of the orbits ; occasionally, openings are found between the 
frontal cells and the orbit or ethmoid cells. They are drained 
by the infundibuli. 

Two sphenoidal sinuses are usually found in the body of 
the sphenoid bone ; they are separated by a thin, bony plate. 
Communication with each superior meatus is accomplished by 
means of a small perforation in the bone. The plate of bone 
which separates these sinuses from the brain is rarely more than 
one-twelfth of an inch thick. 

The antra of Highmore, or maxillary sinuses, are the 
largest of the accessory cavities (see Fig. 1). Each sinus com- 
municates with the upper part of the corresponding middle 
meatus by a duct (occasionally two) large enough to admit an 
ordinary silver probe. This opening is hidden, in the normal 
condition, by the middle turbinated body. The floors are formed 
by the alveolar processes of the superior maxilla, and it is not 
unusual for the roots of the first and second molar teeth to pass 
into these cavities. The roofs of the antra form a part of the 
orbital floors. 

The ethmoid sinuses are composed of a number of small 
cells, thus differing from the other accessory nasal cavities ; in this 
characteristic they resemble the mastoid cells. They are divided 
into two (occasionally three) groups, the anterior and posterior 
ethmoids, — the former opening into the nasal cavity proper, the 
latter into the superior meatus. One of the ethmoid cells is, 
occasionally, so markedly developed as to project prominently 
into the middle meatus. This condition is called by Zuckerkandl 
the bulla ethmoidal is. Rarely, there is a direct communication 



ANATOMY OF THE NOSE. 7 

between the anterior and posterior ethmoidal cells and the sum- 
mit of the antrum. 

The nasal channels, with their prominences, convolutions, 
and accessory cavities, are lined with mucous membrane, con- 
tinuous with that of the pharynx, including the Eustachian 
tubes and middle ears. From the inferior meati, it extends along 
the lachrymal canals to form the conjunctivge. The upper por- 
tions of the nasal cavities — as low as the middle turbinated 
bodies and upper third of the septum — are lined with tessellated 
epithelium, but it is especially important to note that the re- 
mainder of these spaces is lined with ciliated columnar epithe- 
lium. In health the wave-like motion of these cilia helps to 
move the mucus toward the natural outlets, the posterior nares, 
where some suppose it is partly absorbed by Luschka's tonsil, 
while others believe it is directed, by the uvula, to the base of 
the tongue and the lingual tonsil. 

The characteristics of the nasal (pituitary or Schneiderian) 
mucous membrane vary greatly in different localities. It is 
thickest over the turbinated bones and thinnest over the greater 
part of the septum. The thickness of the turbinateds goes far 
toward reducing the size of the nasal chambers, and is par- 
tially due to the abundant supply of glands found in this region. 
The deepest layer of the membrane, that which lies in contact 
with the covering of the inferior turbinated bone, is chiefly an 
erectile, cavernous tissue, a small amount of which is found on 
the crest of the middle turbinated, and another small mass on 
the septum nearly opposite the anterior third of the middle 
spongy bone. This layer is composed of large venous sinuses 
capable of rapid sanguineous distension and sudden erection, 
under vasomotor influence. It is this erection, during acute 
rhinal disorders, which occasions difficult nasal respiration. It 
has been noted that this tissue is frequently erected during men- 
struation and sexual excitement, thus showing a reflex or cor- 
related sympathy between the nose and the sexual sphere. 
Some forms of nasal disorder, especially hypertrophy and ozaena, 



DISEASES OF THE NOSE AND THROAT. 



are aggravated, in certain persons, during the menstrual period, 
and nasal (vicarious) menstruation is a familiar example of 
this correlation. Irritation of these areas may give rise to ren\ex 
symptoms. The mucous lining of the upper, or olfactory, area 
is not very vascular, and contains but a small number of serous 
glands. It is provided with an almost continuous layer of 
branched mucous glands, with ducts opening upon the surface 
of the membrane. Between the tessellated, columnar epithelial 
cells of this region are the delicate, spindle, olfactory cells of 
Schultze, which ramify on the free surface. They are joined to 
a deeper, delicate nerve-plexus, and to the olfactory nerves. 




Fig. 3.— Spheno-palatine Ganglion. (From Sajous.) 

a, Sphenopalatine ganglion ; h, posterior area ; c, middle area ; d, anterior area ; e, olfactory bulb. 

Destruction of these cells causes loss of smell, just as does 
section of the olfactory bulbs or nerves. 

The olfactory nerve (special sense of smell) passes through 
from fifteen to twenty perforations in the cribriform plate of the 
ethmoid bone, and is then distributed to the superior turbinated 
body, to the upper part of the middle spongy bone, and to the 
upper third of the septum. The nasal branches of the spheno- 
palatine ganglion (sympathetic) are distributed to the lower edge 
of the superior, the under surface of the middle, the entire in- 
ferior turbinateds, and to the middle and posterior parts of the 
septum. The vidian passes to the superior spongy bone and to 



PHYSIOLOGY OF THE NOSE. 9 

the superior and posterior portions of the septum. The nasal 
branch of the fifth nerve is distributed to the anterior surface of 
the lower turbinateds, to the floor of the nasal fossae, to the 
upper and anterior portions of the septum, and to the external 
walls of the nasal passages. 

The arteries which supply blood to the nasal cavities are 
the ophthalmic, passing to the vault, upper part of septum, and 
external walls ; the spheno-palatine branches of the internal 
maxillary, to the turbinated bodies, remainder of septum pos- 
teriorly, and the greater portion of the external walls ; and the 
artery of the septum, a branch of the superior coronary, to the 
anterior portion of the septum. The entire arterial supply 
forms a dense net-work in the mucous membrane. The veins 
empty chiefly into the internal jugular, although a few of them 
flow into the veins in the interior of the skull, through the 
cribriform plate of the ethmoid. 

The nasal lymphatics, according to Simon (Schmidt's 
Jahrbuch, Bd. cvii, p. 161), form a wonderfully close intercom- 
municating net-work ; they are especially abundant (1) at the 
upper portion of the superior turbinated body, (2) on the ex- 
ternal face of the middle turbinated, and (3) in the space directly 
anterior. 

Physiology of the Nose. 

The special nasal function is that of olfaction ; its most 
important, respiration. Around these are grouped a number 
of lesser, though important, duties in the human complex. 

The upper portion of the nasal cavities to which the olfac- 
tory nerve is distributed is known as the olfactory tract or area ; 
the lower part, the respiratory. Each of these has its appro- 
priate function. Recent investigations, however, prove that the 
olfactory tract participates in respiration to a slight degree. 

The function of the sense of smell is usually described as 
follows : Odorous bodies cast off minute particles which, float- 
ing in the air, are drawn into the nasal passages during inspira- 
tion, where they come in contact with the terminal olfactory 



10 DISEASES OF THE NOSE AND THROAT. 

fibres. As the mucous membrane in which these nerve-filaments 
terminate is always moist, the odorous particles adhere to it, and 
are speedily dissolved by the mucous secretions, when the pecu- 
liar functions of olfaction are at once established. With most 
substances this process of solution is almost instantaneous, the 
excess of odorous material immediately yielding to the flow of 
mucus excited by the presence of the particles. In this way 
one odor may follow another at a very short interval without, 
in any way, conflicting with the olfactory sense. 

In just what manner the nerve-terminals are affected is an 
unsolved problem. Graham advanced the chemical theory, the 
essential process of which was the oxygenation, within the nasal 
passage, of the odorous particles, thus stimulating the sentient 
olfactory terminals. Ogle promulgated the theory which con- 
nects olfaction with pigmentation, the secretion of pigment by 
Bowman's glands having, according to him, much to do with 
the olfactory sense. Liegeois claims that the odorous particles 
irritate the olfactory terminals mechanically. Ramsey advances 
the theory that olfaction is the result of molecular vibration. 
Tyndal has found that odorous particles act in proportion to 
their heat-absorbing quality. 

It is evident that to have the sense of smell acute the olfac- 
tory mucous membrane must be in a moist condition, its surface 
must be free from dried or thick secretions, nothing should 
prevent the entrance of odorous particles to this tract, the 
nerve-terminals must not be concerned in an hypertrophic proc- 
ess of the mucous membrane, and, finally, the nerve itself, as 
well as its terminals, should be in a healthy condition. In this 
connection Greville MacDonald (" The Forms of Nasal Ob- 
struction ") speaks thus of the functions of the turbinated bodies : 
"Indeed, it would not be incorrect to style the superior spongy 
bone the organ of taste, the middle turbinated and plain surface 
of the ethmoid that of smell." In explanation, he says that " the 
expired air, which during mastication is laden with odoriferous 
particles, is driven by the thorax directly upwards to the vault 



PHYSIOLOGY OF THE NOSE. 11 

of the nasopharynx, and readily comes in contact with the pro- 
jecting superior turbinated bone, over which is distributed the 
posterior division of the olfactory nerve." 

The proper respiratory channel is the nose, not the mouth. 
Nature so constructed the nasal fossae that cold air is elevated 
in temperature during its passage over this area, which is con- 
stantly warmed by the free circulation of blood. Aschenbrandt, 
Kayser, and MacDonald have shown that if the inspired air 
enter one nostril at from 46.4° to 53.6° F. (8° to 12° C.) it will 
pass out through the opposite nostril, without having reached 
the lungs, at the uniform temperature of 86° F. (30° C.) ; or, 
the same as the usual expiratory current. According to the 
experiments of MacDonald (" Respiratory Functions of the 
Nose"), air at 19.4° F. (7° C), "breathed in and out of the 
lungs only, without the intervention of the nose, was raised to 
92.3° F. (33.5° C.) ; whereas, when breathing was conducted in 
at the nose and out at the mouth, the thermometer indicated 
95° F. (35° C), the duration of the respiratory acts occupying 
the same number of seconds in each case." When air passed 
in through one nostril and out through the other without enter- 
ing the deeper respiratory passages, the temperature arose to 
86° F. (30° C). " A noteworthy fact, moreover, is, that co- 
caine, by ansemizing and inducing collapse of this [intra-nasal] 
tissue, lessens the acquired temperature by two or three de- 
grees." Hot air absorbs moisture from the tissues, thus lower- 
ing its temperature ; for it is generally stated that a pint or more 
of serum, composed of 92 to 93 per cent of water, the remainder 
of solid matter, is poured out by the venous sinuses of the nose 
each twenty-four hours. Very dry air is moistened and ren- 
dered more suitable for contact with the throat and deeper 
respiratory tract, which would otherwise be dried and irritated. 
Very moist air gives up some of its humidity on coming in 
contact with the mucous lining. Dust-laden and smoky air 
is much purified and sifted by the little hairy processes (the 
vibrissa), contact with the moist mucous tissue arrests other par- 



12 DISEASES OF THE NOSE AND THROAT. 

tides, and the cilia? of the membrane aid greatly in this process 
of filtration. The vibrissa? also guard against the entrance of 
insects. Finally, the olfactory nerve warns of the presence of 
many deleterious substances. 

Air thus inhaled passes through a narrow, tortuous tract, 
perhaps in rotary motion ; so that, doubtless, all of it comes in 
contact with some portion of the nasal canal, thus rendering it 
capable of safe respiration. Any affection or condition which 
interferes with these various functions not only leads to nasal 
disorders, but goes far to establish disease of other organs di- 
rectly allied, especially the pharynx, larynx, trachea, and lungs ; 
and it may induce reflex cough, asthma, nasal vertigo, and 
similar phenomena. 

The resonant function of the nasal fossa? is a very important 
one. This duty on the part of the nose is not confined to its 
canals, for the bones participate in the vibratory process, and it 
is believed that much of the resonance of the voice depends 
upon the collateral sinuses. If these be obstructed by tumors, 
abscesses, etc., the vocal tones are impure. When the nasal 
fossa? are obstructed in any manner, defective speech is marked. 

The greater number of both vowel and consonant sounds 
depend for their purity upon the nose and its surrounding struc- 
tures ; hence, it may be said that upon the nose (aided by the 
epiglottis) chiefly depends the vocal timbre, — that peculiar 
feature which constitutes the especial quality by which we can 
distinguish one voice from another. The immediate destruction 
of the timbre can be brought about by the closure of the nos- 
trils between the thumb and finger, — a simple experiment 
which proves the part assumed by the nose in the production 
of pure tone. Even should the nasal canals be normal and the 
pneumatic spaces in good condition, much depends upon the 
prompt action of the soft palate and epiglottis in controlling the 
column of sound-waves set in sonorous vibration at the vocal 
bands. This action is a constant one, both in speech and song. 
When certain sounds are articulated, — for example, m and n, — 



PHYSIOLOGY OF THE NOSE. 13 

the palate is relaxed and a large column of air is set into vibra- 
tion within the nasal chambers ; when u is uttered, the highest 
degree of palatal tension is assumed, little vibration occurring 
in the nasal air-column. Between these extremes are the vari- 
ous grades of tension and relaxation required for the production 
of other sounds. 






CHAPTER II. 

Rhinoscopy — Examination of the Nasal 
Passages. 

A limited inspection of the anterior portion of the nasal 
fossae (the vestibules) may be made by elevating the tip of the 
nose while the patient faces a window, sunlight, or an artificial 
light in such a way as to have the rays pass through the nostrils. 

In order, however, to make a more extended examination, 
some accessory appliances are necessary. For this purpose any 
smooth, small instrument, similar to a narrow spatula, may be 
inserted within the vestibule and made to push the ala directly 
outward ; but as this procedure permits a limited view only, 




Fig. 4.— Kramer's Speculum. 



numerous specula have been devised for dilating the nostrils and 
revealing the deeper parts. These nostril-dilators are occasion- 
ally made with three blades, but are preferably bivalved. The 
blades may be fenestrated or solid ; the latter are the better, as 
the vibrissas often protrude through the former and greatly ob- 
struct the view. Nasal specula are either self-retaining or so 
constructed as to render it necessary to hold them in position ; 
the former are to be preferred, unless the patient be refractory 
or the canal obstructed near the nostril. Nasal specula are also 
made of plates of solid metal or are composed chiefly of wire. 
Of the former, I usually use Kramer's ; of the latter, the one 
(14) 



RHINOSCOPY EXAMINATION OF THE NASAL PASSAGES. 



15 



pictured below (Fig. 5), which is self-retaining, simple in con- 
struction, and thoroughly aseptic. A double coil of wire at the 
spring end renders the speculum so elastic as to rarely cause 
pain while in position ; as a further result of this double coil, 
the instrument has a slight antero-posterior motion, thus allow- 
ing the septal blade to be drawn forward in front of the sensitive, 
bony septum, while the alar blade is well introduced for more 
complete dilatation of this portion. Oval, hard-rubber specula 




EAYARMAIL C.: > _ . 



-Author's Self-retaining Wire 
Speculum. 



Fig. 6.— Oval. Hard-rubber 
Speculum. 



are preferable when applying acids to the nasal passages. 
Zaufal employs a long, slender, hard-rubber tube for exploring 
the parts about the posterior nares. 

For purposes of illumination ordinary daylight can be 
utilized as suggested, but, as this is usually too diffused, it is 
better to make use of the sun's rays or some form of artificial 
light. Gas-light furnished by an Argand burner is mostly 



OOO 




E.A.yA/f A/ALL -CO. P/MA. 

Fig. 7.— Zaufal's Speculum. 



employed, because more easily controlled ; but it is not always 
sufficiently powerful for examining the trachea, when it may be 
necessary to employ electricity, magnesium wire, oxyhydrogen, 
lime, or some equally powerful illuminant. A very good light, 
as suggested by Sajous (" Diseases of the Nose and Throat "), is 
obtainable by dropping a small piece of gum-camphor into the 
tank of an oil-lamp. Transillumination, by placing an illumi- 
nated glass rod against the skin surface, is sometimes of value. 



16 



DISEASES OF THE NOSE AND THROAT. 



When ready for the examination the room should be dark- 
ened. If sunlight be the ilium inant, it is best to have a small 
hole in the shutter or blind, through which the pencil of rays 
may pass ; but a good examination may be made without dark- 
ening the room. Where direct artificial illumination is used, the 
light is placed ten or twelve inches in front of the patient's face. 
The examiner either stands or seats himself before the patient, 
with the light passing into the nostril. In this position he 




Fig. 



Akgand Gas. Bracket with Three Arms. 



places one hand and arm on each side of the light, — an awk- 
ward position, and one which hinders the free movements so 
essential to easy examination and operation. The presence of 
the bright light is a further hindrance, but this may be kept 
from the patient's eyes by a shade, and from the examiner's by 
a screen or reflector placed between him and the luminous point. 
It is much better, therefore, to use reflected artificial light, when 
the luminous point should be nearly on a level with the patient's 
ear and a little behind it. If the light be a strong one, such as 



RHINOSCOPY EXAMINATION OF THE NASAL PASSAGES. 



17 



the lime-light, it may be conducted through a tube passing over 
the operator's shoulder and opening near the patient's nose 
(Fauvel and Mackenzie). A small incandescent lamp may be 
attached to the front of a head-band (photophore) , by which the 
light is thrown directly to the point 
desired. This is more or less cum- 
bersome (although now made of alu- 
minium) and necessitates wire at- 
tachments to the battery or dynamo. 

When reflected light is used, 
it is necessary to resort to an extra 
mirror known as the reflector, or 
head-mirror. This should be con- 
cave if artificial light be used, and plain if sunlight be the source 
of illumination. 

Some prefer to wear the mirror above, others below, the 




Fig. 9.— Mackenzie's Condenser 
fob Argand Burner. 




eyes ; but in order to obtain the most direct return of the rays 
of light the perforation in the mirror should be placed directly 
in front of one eye. 

In order to complete the reflecting apparatus, it is necessary 



18 



DISEASES OF THE NOSE AND THROAT. 



to have some form of handle or attachment. In this country, 
a head-band is usually employed (see Fig. 11), but some prefer 
to attach the mirror to a heavy spectacle-frame, while others 




Fig. 11.— Head-Mirror with Band and Handle 



think it more convenient to use a steel spring passing over the 
vertex to the occiput. 

When ready for examination the physician seats himself 




Fig. 12.-Si'ectacle-Frame. 



or stands in front of the patient, who inclines his head slightly 
backward. 

The tip and external surface of the nose having been 
inspected, a closed nasal speculum is to be introduced. The 
instrument is held in the right hand for examination of the 



RHINOSCOPY EXAMINATION OF THE NASAL PASSAGES. 



19 



left nasal fossa, and in the left hand for the right fossa. When 
well within the vestibule, the blades are separated or allowed to 
separate according to the construction of the instrument. Care 
must be taken neither to introduce the speculum sufficiently far 
to press against the sensitive bony septum nor to dilate the 
nostril so forcibly as to cause pain. 

With the speculum in position, the anterior rhinoscopic 
appearances may be distinguished. In order to view all the 




Fig. 13.— Position for Anterior Rhinoscopy. (From a photograph.) 

parts, it is necessary to slightly change the direction of the 
speculum and the position of the head from time to time. It 
must be remembered that there are great variations within an- 
atomical and physiological limits ; for instance, the septum is 
nearly always slightly deflected, one passage may be somewhat 
larger than the other, both may be larger or smaller than the 
average, the turbinated bodies may have unusual or irregular 
forms, etc. 

The septum should claim our attention first. It should be 



20 DISEASES OF THE NOSE AND THROAT. 

comparatively vertical and smooth, with the exception of the 
tubercle. Along the inferior meatus we should see almost to 
the posterior pharyngeal wall. Opposite the septum (see 
Frontispiece and Figs. 1 and 2), but separated from it, should 
appear the inferior turbinated body, below which is the inferior 
meatus ; above the inferior body and posterior to its anterior 
extremity appear the middle meatus and turbinated ; above, and 
still more posteriorly, a light-pink ridge, the so-called superior 
turbinated, may occasionally be seen. These scroll-like bodies 
should be separated from each other and from the septum, 
otherwise the condition constitutes a pathological alteration. 
The inferior body is distinguished from the rest of the struc- 
tures seen by anterior rhinoscopy by its bright hue and greater 
roundness ; the septum is rather paler (especially over the 
cartilaginous portion) ; and the middle body is similar to it, 
while the paleness of the superior turbinated (when visible) is 
pronounced. The late Professor Voltolini, with the idea of 
obtaining a better view of the deeper parts, recommended that 
an assistant illuminate the naso-pharynx while the nose is 
examined anteriorly ; but the practical utility of the suggestion 
is not apparent. 

For posterior rhinoscopy a different instrument is necessary 
and different methods are to be employed. The illumination 
and the relative positions of patient and examiner are the same, 
except that the head of the former is thrown slightly forward 
with the mouth open. The examiner so places himself that he 
can see well into the patient's open mouth. The speculum is 
supplanted by the rhinoscopic mirror, which, in its usual form, 
consists of a small-sized, usually No. 3, laryngeal mirror ; but, 
in order to obtain the most satisfactory image, it is advisable to 
have a mirror so constructed that its angle can be varied at will ; 
thus, when it is necessary to see directly upward the angle 
formed by the mirror and handle may be 170 degrees, and 
when nearly forward an angle of 100 degrees may be needed. 
Frankel's rhinoscopic mirror accomplishes this object, as its 



RHINOSCOPY EXAMINATION OF THE NASAL PASSAGES. 21 

angle can be altered by slight pressure of the thumb. It may 
be stated, in general, that the larger the mirror, within easy 
limits of use, the better and more satisfactory the image. The 
picture is never complete in posterior rhinoscopy, unless there 
be a cleft in the soft palate ; it is necessary, therefore, to fre- 
quently alter the position of the mirror for the better inspection 
of the various portions. 



eayaftnall co. phila. 

Fig. 14.— Rhinoscopic Mirror. 



For the consolation of those who fail in their earlier 
attempts, it may be noted that posterior rhinoscopy is far more 
difficult of accomplishment than anterior rhinoscopy, otoscopy, 
ophthalmoscopy, or laryngoscopy. 

With patient and physician in readiness, the rhinoscopic 
mirror, with the glass surface downward, is to be warmed over 
a gas-lamp or candle-flame, or by dipping it into hot water and 




Fig. 15.— Fhakkel's Rhinoscopic Mirror. 

drying. Its temperature should be tested by placing its back 
against the palm of the hand. The mirror must not be warm 
enough to injure the delicate mucous lining, though sufficiently 
heated to prevent its surface from becoming dimmed by the con- 
densation of moisture from the exhaled air. With the patient's 
mouth well opened, the light is directed to the back of the 
pharynx, where the warmed mirror is introduced with its reflect- 



22 



DISEASES OF THE NOSE AND THROAT. 



ing surface upward, the stem of the mirror usually fulfilling 
the requirements of a tongue-depressor. The mirror is gradually 
slipped backward, until the reflecting surface is back of the soft 
palate and uvula and a little to one side of the latter ; but care 



£-***) 




Fig. 16 — Rhinoscopic Mirror in Position. (From a photograph.) 



must be exercised not to touch the pharyngeal wall, lest reac- 
tion follow. Much care and patience will sometimes be de- 
manded to get the mirror in its proper position. The patient 
should be directed to breathe through the nose as quietly and 



RHINOSCOPY EXAMINATION OF THE NASAL PASSAGES. 23 

naturally as possible, in order that the soft palate may fall for- 
ward away from the pharynx, thus permitting- a reflection of the 
parts back and above the curtain. If the soft palate do not fall 
forward, the patient should sound the syllable " ang " or " ung," 
or be directed to "sniff the air" as in smelling. In difficult 
examinations the patient's face should be inclined downward, 
the examiner looking from below upward. Failing in the pre- 
ceding measures, the patient should rest a few minutes before 
the attempt is repeated, or he may be given iced water or pieces 
of ice to hold in his mouth for the purpose of reducing the reflex 
irritability. A spray of a 2-per-cent solution of hydrochlorate 
of cocaine is occasionally necessary. 

Failure seldom follows the exercise of care, patience, and 
dexterity, although at times the tonsils may be so large, the 
uvula so elongated, and the palatopharyngeal space so shallow, 
antero-posteriorly, as to prevent a successful examination. 
Again, adhesions may exist to such an extent as to absolutely 
preclude a view of the naso-pharynx. In some cases a large, 
highly-arched tongue is difficult to control, when a depressor 
may be needed. For this purpose the back of a second mirror, 
the index finger of the free hand, or an ordinary tongue- 
depressor may be used. Palate-hooks have been devised for 
holding the soft palate and uvula forward, but they are rarely 
needed except during operations ; even then it is usually more 
satisfactory to pass a piece of fine drainage tubing through the 
inferior nasal passages (one end through each side) into the 
pharynx, and when drawn out of the mouth the ends are tied 
to the loop which passes over the columella. This serves to 
hold the soft palate and uvula forward, and seldom causes more 
than slight annoyance to the patient. 

The posterior rhinoscopic image, as stated, is necessarily 
quite limited, and the completed picture more or less diagram- 
matic. The septum can be seen as a straight vertical line, 
sometimes pale in color ; on either side will be noticed dark 
spaces or caverns, — the openings into the posterior nares or 



24 DISEASES OF THE NOSE AND THROAT. 

choanse. At the sides of these openings, opposite the septum, 
may be seen either whitish or pale rose-colored, smooth, round- 
ing projections, — the turbinateds. While the inferior appears 
the largest by anterior rhinoscopy, the middle occupies that dis- 
tinction posteriorly, and is often very prominent. The upper 
turbinated is small and pale, while the inferior is deeper in color 
and not always visible, on account of the projection backward 
and upward of the soft palate and its cushion ; a fourth spongy 
body is occasionally visible, on one or both sides. Between the 
turbinateds are the meati, as in front, but the lower is rarely 
visible in the rhinoscopic mirror unless there be cleft palate. 



W< 



Fig. 17.— Posterior Rhinoscopic Image. (Modified from Sajous.) 

The other spaces appear as dark, shadowy cavities. The pos- 
terior surface of the veil of the palate and uvula appears below 
the posterior nares ; above them, in the vault of the pharynx, 
is seen the pharyngeal, or Luschka's, tonsil. On each side of 
the naso-phar.ynx, just below the level of the middle meatus, is 
a pale crater or cup-shaped depression, — the entrance to the 
Eustachian tube, — formed by the projecting salpingo-palatine 
fold in front and the salpingo-pharyngeal fold behind. (See 
Figs. 2 and 17.) Directly back of the latter is a deep groove, 
the fos?a of Rosenmiiller, the two being separated by the 
Eustachian cushion, — the posterior cartilaginous wall of the 
Eustachian tube. 



RHINOSCOPY EXAMINATION OF THE NASAL PASSAGES. 



25 






Although the mirror furnishes a satisfactory view in most 
cases, there are others, as stated, in which it is not sufficient ; 
and if there be reason to suspect hidden mischief in this region, 
the parts should be further explored by passing the index 
finger back of the soft palate ; this causes little pain, although 
quite annoying to most persons. When using the finger the 
right side of the patient's head should be held against the ex- 
aminer's chest or abdomen with the left hand, the middle finger 
pressing the cheek between the teeth to pre- 
vent biting. The right index finger (thor- 
oughly guarded when examining children) is 
to be introduced and carefully moved about, to 
ascertain the condition of the naso-pharynx. 
This, of course, presupposes accurate anatomi- 
cal knowledge, which it is well for the examiner to gain from 
normal subjects. Spasm will at once follow the introduction 
of the finger, but is seldom so persistent as to prevent the com- 
pletion of the examination. It is best to insert the tip of the 
finger well to the side of the pharynx, back of the posterior 
faucial pillar, as there is less muscular resistance at that point. 
When once in the naso-pharynx, it can easily be moved to any 
portion of this cavity. Care should be exercised that respiration 
be not suspended by the presence of the finger. 




Fig. 18.— Finger- 
Guard. 



CHAPTER III. 

Catarrhal Diseases of the Nasal Cavities. 



CORYZA ACUTE NASAL CATARRH ACUTE RHINITIS. 

In temperate climates this is the commonest of all diseases; 
there are few persons who do not suffer occasionally. The 
affection and most of its causes are well known, but whether it 
be infectious in its uncomplicated form has not been determined. 
When a part of the exanthemata, it is probable that the dis- 
charges from the nose augment the contagious character of these 
affections. The nasal flow is irritating, saline, and strongly 
alkaline, — due either to hydrochlorate of ammonia in excess 
(Bonders) or to micro-organisms. 

Etiology. — The sudden changes of temperature and the 
chilling of the overheated or sensitive body by draughts of air 
are the most frequent causes. Other excitants are : damp or wet 
feet or clothing ; exposure to dry heat, irritating dust, chemi- 
cals, various fumes, high winds; sleeping in draughts; indiges- 
tion; insufficient sleep; etc. Children are attacked more fre- 
quently than adults. Those accustomed to fresh air suffer less 
than those who are housed. 

Pathology. — It is generally taught that "rhinal inflamma- 
tion invariably commences on the superior and middle turbinate 
process and extends in all directions." In the beginning, the 
vessels of the nasal mucous membrane are contracted, the cir- 
culation is increased, and there is little or no secretion ; later, 
vascular dilatation occurs owing to vasomotor paresis, the blood- 
current is retarded, blood-stasis is established, accompanied by 
the escape of liquor sanguinis, with increased flow of mucus 
and a watery secretion. This soon becomes thick and puriform 
owing to the great number of young cells and epithelial scales, 
upon which the color of the discharge depends. As resolution 
(26) 



CORYZA ACUTE NASAL CATARRH ACUTE RHINITIS. 27 

takes place the vessels regain their tone and the parts return to 
the normal state. When resolution is slow, the vessels and 
surrounding tissues do not promptly recover their vitality ; as a 
result, chronic catarrh is established. 

Symptoms. — The onset of acute coryza is generally sudden. 
The first symptom is often a tingling or tickling in the nose, 
frequently accompanied by sneezing ; a dry, burning, or full 
feeling in the nose or head ; a cold sensation in the region of 
the frontal cells ; frontal or occipital headache ; coldness and 
stiffness of the back of the neck ; malaise ; burning eyes, and 
sometimes fever. With the progress of the attack the sneezing 
increases, the headache grows more intense, the nose becomes 
more obstructed, nasal respiration is difficult, and the voice dis- 
tinctly " nasal " and dull. At first there is rarely much dis- 
charge from the nose, but after a few hours, possibly days, a 
thin, excoriating, or bland watery flow is established. From 
one to four days from the onset, the discharge becomes copious, 
thick, occasionally brown or bloody, but usually yellow or green, 
owing to the escape of numbers of unripe leucocytes and epithe- 
lial scales. In some cases there are well-defined haemorrhages. 
Occasionally, at this stage, the pain in the frontal region be- 
comes very severe, often almost unendurable, owing to con- 
gestion, inflammation, or abscess of the frontal sinuses. When 
the discharge from the nose becomes thick and profuse, the 
pain in the head decreases, the feeling of malaise, feverishness, 
dry lips, etc., abate, and nasal respiration becomes easier. This 
affection is liable to be confused with neurotic swelling of the 
erectile tissue, in which, however, there is neither malaise nor 
fever. Inspection reveals the existence of a red or purple color 
of the turbinated bodies, which are swelled, dry, and glazed in 
the early stage ; later, there is less tension, the glazing gives 
place to a serous coating, and the color of the membrane is 
more rosy. Before the close of the attack the characteristic 
discharge is seen, the membrane gradually resumes its normal 
color, and the swelling subsides. 



28 DISEASES OF THE NOSE AND THROAT. 

Course. — The course of the disease varies from one to ten 
days or longer. If the patient be seen early, the attack can 
usually be aborted ; but if nothing be done until the coryza is 
well established, the time of treatment varies from one to seven 
days, perhaps longer, or chronic catarrh may follow. Many 
members of the dominant school claim that coryza must run its 
course, and that little or nothing can be done after its thorough 
establishment. This does not accord with our experience. 

Prognosis. — The prognosis is generally good. In infants 
and in the aged and debilitated, acute nasal catarrh may 
terminate fatally. 

Treatment. — The treatment is both abortive and curative. 
In the first stage, during sneezing, tingling, burning, and dry- 




Fig. 19.— Burgess' Atomizers. 

(To be nsed either by hand or by attaching to an air-corn pressor, which see.) 

ness in the nose, pain and tired feeling in the muscles of the 
neck, a compressible pulse, general lassitude, especially if the 
weather be warm, moist, and relaxing, nothing seems so 
effectual in checking the progress of the " cold " as gelsemium ; 
although it has a rival in quillaia, especially for cold contracted 
during warm, damp weather. When there are sneezing, ma- 
laise, thirst, dry lips, congested conjunctivae, aching in the back 
and limbs, and full pulse, aconite proves abortive, in a large 
number of cases. With sudden fullness of the nasal passages 
and little sneezing, and an intense burning in the nasal canals, 
camphor acts promptly. This drug may be used internally, or 
inhaled from the hands. Menthol may be inhaled from crystals 
heated in boiling water, but a more efficient method is to employ 



CORYZA ACUTE NASAL CATARRH ACUTE RHINITIS. 



29 



a fluid cosmolin, vaselin, or albolene spray of a 1- to 2-per- 
cent menthol solution. The spray may be repeated two or 
three times during the first hour or two ; less frequently later. 
When the forehead, in the region of the frontal sinuses, feels 
cold, the attack may often be broken by placing a piece of 
flannel or some other warm article over the cold area, including 
the upper portion of the nose. A hot-water bag is the most 
pleasant manner of accomplishing this result, in the majority of 




Fig. 20.— Aik-Compkkssoh, with Two Outlets. 



cases. Rubbing the sides of the nose and forehead with the 
hand or a piece of silk, brisk exercise, deep nasal respiration, 
and hot drinks, followed by sweating in bed, often so restore 
the balance of circulation as to avert the attack. 

When nasal respiration is greatly impaired, especially in 
children, a cosmolin, albolene, Russian voschano-oil, or men- 
thol spray often acts admirably ; but it may be advisable to 
make semi-daily use of a 1- to 2-per-cent cocaine application, 
either in glycerin and water (equal parts) or in cosmolin. 



30 DISEASES OF THE NOSE AND THROAT. 

The great prophylactics are hygienic and dietetic. The 
outside wraps should be removed immediately after entering a 
warm room, and the neck and chest should be sponged daily 
with cold water, immediately followed by brisk friction. Turk- 
ish baths are sometimes useful, but do not agree with all. 

The diet need not be changed during the attack, but large 
draughts of water seem to favor elimination. 

Therapeutics. 

Aeon, not only serves to abort the attack, as stated, but is 
later indicated for headache, sneezing, watery discharge from 
the eyes and nose, malaise, thirst, and scanty but frequent 
urination. 

Ammon. carb. — Nose stopped up at night; patient wakes 
about three or four a.m. gasping for breath. Nostrils sore, raw ; 
coryza scalding, excoriating upper lip ; burning and fullness in 
the throat. 

Antipyrin 1 c. — '-When waking at night, sudden, profuse 
perspiration ; simultaneously, profuse coryza, accompanied by 
almost constant sneezing, burning in the nose, and profuse 
watery discharge." (TV. M. Decker, N. A. Jour. Horn., March, 
1889.) 

Ars. — Persons who are rarely without " a cold." Repeated 
sneezing without relief, but followed by copious, watery dis- 
charge, which burns and excoriates the nostrils and lip ; later, 
thick, yellow, muco-purulent flow. Frontal headache, with 
nasal asthma. Burning in the nasal fossae and throat ; hoarse- 
ness, especially when the symptoms are relieved by warmth. 
"■ When painful pimples form within the orifice of the nostril, 
causing external tenderness, redness, and swelling." (George 
Moore, "Nose and Throat Diseases.") 

Bell. — Acrid, watery nasal flow ; frequent sneezing, which 
causes headache ; erysipelatous redness of the nose, with chilli- 
ness. Throat dry, painful, and bright red ; tonsils inflamed ; 
difficult or painful deglutition. 



THERAPEUTICS OF ACUTE RHINITIS. 31 

Camph. — Involvement of the frontal sinuses; dull, pressive 
headache ; free watery discharge from the nose and eyes ; par- 
oxysms of sneezing, especially in the morning ; malaise. 

Cepa. — Upper lip excoriated ; nasal secretion watery and 
acrid, with a bland flow of tears (euphrasia the reverse) ; itching, 
burning, and stinging in the eyes. Worse in a warm room ; 
better in the open air (puis.). Laryngeal cough and tingling 
pain. 

Dulcam. "is the principal remedy in coryza neonatorum. 
This is an absolutely clinical indication." (P. Jousset.) When 
the coryza is worse or suppressed by every cold change in the 
weather ; aggravated by dampness ; nose obstructed ; hoarse- 
ness. 

Euph. is said to abort coryza. It is later indicated for very 
profuse, non-corroding nasal discharge, with excoriating lachry- 
mation ; ulcerated lid-margins ; upper lip feels stiff. 

Fer. phos. — First stage of cold in the head, with circulatory 
disturbances, catarrhal fever, congestion of nasal mucous mem- 
brane; and for a cold-catching predisposition (calc. phos.). 

Gels, differs from aeon, in that the attacks often recur in 
summer ; the back feels chilly ; fullness in the head ; redness 
and soreness of the nostrils ; heat of the face ; beating of the 
carotids, and a feeling of languor or drowsiness. 

Hydrast. — Thin, watery discharge, attended with much burn- 
ing and rawness, and a sensation of a hair in the nose ; frontal 
headache ; mucous obstruction of the naso-pharynx ; constipation. 

Kali bi. — "An invaluable remedy when the discharge from 
the nose is tough and stringy ; sometimes it seems to extend to 
the throat and to cause choking." (Guernsey's " Obstetrics.") 
Pressure at the root of the nose, with dull, heavy, frontal head- 
ache, relieved by pressing the bridge of the nose. 

Kali iod. — Profuse, watery coryza and lachrymation ; later, 
offensive dark-green or yellowish discharge ; epistaxis ; tight, 
full feeling and throbbing in nasal bones ; involvement of the 
antra of High more and frontal cells ; conjunctivitis ; lachry- 



32 DISEASES OF THE NOSE AND THROAT. 

mation ; sticking pains in the ears; syphilitic and scrofulous 
subjects. 

Magnes. mur. has proved curative for loss of taste and smell 
following colds. 

Merc. sol. — Nose swelled, red, and sore ; the alaa and colu- 
mella excoriated ; sneezing and watery discharge ; in nam mation 
of the conjunctiva and linings of the pharynx, larynx, and 
trachea ; yellowish-green, thick, muco-purulent (puis.), irrita- 
ting discharge. 

Natr. mur. — "Fluent coryza in chilly subjects; chills along 
the back ; great thirst ; vesicles on the lips or tendency to them ; 
constipation ; weight in forehead on rising in the morning ; sad- 
ness, depression, tendency to weep. Aggravation of symptoms in 
the morning and periodically ." (J. H. Clarke, "Cold-catching, 
Cold-preventing, Cold-curing.") 

Nux vom. — Alternately free and obstructed nasal passages, 
and in the initial stage if caused by dry, cold weather, or by 
sitting on cold steps, etc. ; sneezing and nasal obstruction ; 
lachrymation and scraping roughness in the throat, but no nasal 
discharge. The nose is very dry at night, especially toward 
morning. Dry cough due to tickling in the larynx; constipation. 

Osmium, according to the late Dr. E. A. Farrington, "rivals 
the more commonly employed phosphorus. It is highly irrita- 
ting to mucous surfaces, provoking coryza, sneezing as from snuff; 
nose and larynx sensitive to the air. Small lumps of phlegm 
are easily loosened from the posterior nares and larynx. Like 
phosphorus, it attacks larynx and lungs. Characteristic is severe 
pain in the larynx, worse when coughing or talking ; hoarse- 
ness." {Trans. Horn. Med. Soc, State of Pennsylvania, 1S83.) 

Puis. — Yellowish-green, thick, and often fetid discharge ; 
of use especially in the later stages (kali mur.) ; always better 
in the open air. This remedy is chiefly curative in low dilutions 
and in frequently repeated doses. 

Quil. — "For dry or fluent coryza and frequent sneezing; 
dull pain in head at root of nose ; dull, heavy pain in both 



RHINORRHCEA NASAL HYDRORRHEA. 33 

temples, with scraping sensation in pharynx; throat very sore, 
especially on swallowing ; tonsils swollen ; weary feeling in 
limbs; lassitude." (The California Horn., September, 1889.) 

Sang. can. — Much soreness of the palate and pharynx, right 
side worse. The throat feels dry, raw, burning, as if scalded 
or denuded ; loss of taste and smell ; much sneezing ; acrid, 
fluent coryza ; nostrils sore, and pain through the nasal bones ; 
catarrhal headache ; Eustachian deafness ; vertigo ; susceptibility 
to odors, which sometimes cause faintness, especially in hay 
fever. 

Verbasc. — "Acute or chronic rhinitis, with a periodically 
(often twice daily) returning neuralgia of the face ; voice deep, 
hard, and very hollow." (Farrington.) 

RHINORRH(EA NASAL HYDRORRHEA. 

Etiology, — Although rare, cases are not wanting in which, 
with apparently slight nasal irritation, there is a free watery 
flow from the nose, usually lasting some weeks, and with a dis- 
position to become chronic. The daily discharge is often very 
profuse, — sometimes two or three quarts, — but seemingly not 
debilitating. As a rule, there is only a subacute nasal catarrh, 
but hypertrophy and even polypi may exist. The external nose 
is generally irritated, even sore, and the upper lip may be in- 
flamed and scaly. The watery flow seems to be the result of 
vasomotor paralysis, and is, apparently, often due to some atmos- 
pheric influence or irritant, or to a lesion of the trifacial nerve. 

Symptoms. — The symptoms are suggestive of hay fever, 
but rhinorrhcea is not confined to pollen-forming periods, being 
more or less constant. The sneezing is often exceedingly annoy- 
ing and the discharge very distressing and constant in most 
cases, but in others it has certain fixed daily aggravations. It 
may be painless or accompanied by neuralgia and intense irrita- 
tion of the nasal mucous membrane. Difficult nasal respiration 
is often present, owing to engorged turbinated covering or other 
defects. Optic-nerve atrophy is, apparently, an occasional result. 



34 DISEASES OF THE NOSE AND THROAT. 

Prognosis. — The prognosis is usually favorable, although a 
speedy cure should not be expected, as the condition sometimes 
lasts a number of years. 

Treatment. — Mechanical treatment may be used to advan- 
tage, directions for which will be given under the disease causing 
or complicating this affection. Cocaine or menthol, 1 to 3 per 
cent, often gives temporary relief. A 30-per-cent glycerin and 
water spray is often of decided utility, while, internally, ars., 
arum tri., cepa, cham., gels., kali iod., and naphthalin are fre- 
quently indicated. 

CHRONIC NASAL CATARRH CHRONIC RHINITIS. 

Etiology. — Ordinary chronic nasal catarrh is a frequent 
result of the acute form of the disease. It may follow trauma- 
tism and various irritants, but cases arise in which it is impossible 
to assign any cause, the condition seeming to be chronic from 
its inception. The ordinary form of this affection is not usually 
described, as it is generally classed with the hypertrophic variety ; 
but there seems no good reason for denying the existence of a 
chronic catarrh of the nasal mucous membrane, independent 
of a pure hypertrophy. It is true that with this affection there 
is some thickening (swelling, engorgement, turgescence) of the 
Schneiderian membrane, but it is not hypertrophic, as cocaine 
reduces it at once and pressure with a probe leaves a decided 
indentation, which slowly passes away. With true hypertrophy, 
the tumefaction will not entirely disappear under the action of 
cocaine, nor can the tissues be decidedly pitted without consid- 
erable force ; even then they promptly resume their form. This 
swelling of chronic rhinitis is chiefly confined to the turbinated 
bodies, but it is not infrequently found on one or both sides of 
the septum, constituting a well-marked submucous infiltration. 

There is, no doubt, some increase in the cell-elements, but 
it is slight ; the chief cause of the enlargement, in simple chronic 
coryza, is the overfilling of the vascular anastomoses and the 
erection of the nasal corpora cavernosa, or erectile tissue. 



CHRONIC NASAL CATARRH CHRONIC RHINITIS. 35 

Symptoms. — The symptoms are usually distinct. Starting 
in repeated attacks of the acute condition, or resolution not 
following- the first seizure, the patient is troubled with an irrita- 
tion of the nose, a sensation of fullness, difficult nasal breathing, 
and a slightly " nasal " voice ; but the most important and 
characteristic indication is the presence of an annoying discharge. 
This may be thin or thick, scant or copious, bland or excori- 
ating ; or white, discolored, or bloody. It often dries on the 
septum and other portions of the nasal fossae, causing tickling, 
fullness, or pain. This form of the affection constitutes simple dry 
rhinitis, and is entirely distinct from muco-purulent dry rhinitis, 
due to atrophy. Although much of the discharge is" expelled 
through the anterior nares, a large portion passes into the throat, 
and is removed as screatus, by hawking. Sneezing is rather 
frequent, and where the infundibulum is involved the frontal 
cells usually participate and occasion headache. In the same 
manner the antra of Highmore. the sphenoid and ethmoid 
sinuses, and the lachrymal apparatus may be invaded, causing 
symptoms to be considered later. As complications, there may 
be granulation tissue or polypoid growths ; as sequelae, hyper- 
trophic or atrophic catarrh or ozaena. The affection is worse in 
spring, autumn, and winter ; in the mild weather of summer 
there may be little or no annoyance. 

Prognosis. — The prognosis is generally good, but as the 
disease is apt to be aggravated by acute exacerbations, due 
to frequent atmospheric changes, too favorable a prognosis 
should not be given ; and, even after recovery, there is always the 
possibility that, unless carefully watched, the affection will return 
with the first attack of acute nasal catarrh. 

Treatment. — The treatment should be constitutional and 
often local. Under the former are included diet, hygiene, and 
internal remedies. Even though denied by most writers, it is 
well to remember that the state of the general system has much 
to do with the affection ; on this account, constitutional remedies 
do more good than is usually attributed to them. 



36 



DISEASES OF THE NOSE AND THROAT. 



Among local measures, cleanliness is of importance when a 
profuse, glutinous discharge prevents nasal respiration or inter- 
feres with medicinal applications directly to the lining membrane. 
For cleansing purposes a solution of half a teaspoonful of salt, a 
quarter teaspoonful of baking soda, and half a glassful of warm 
water is practically the most efficient. It is to 
be either drawn up into the nose from the palm 
of the hand or from a U- or cup- shaped nasal 
tube, or introduced through the mouth and 
back of the soft palate to the nose by means of 
a hard-rubber post-nasal syringe. Evacuation 
occurs through the anterior nares, where a 
bowl or basin is held to receive the fluid. The 
clothing should be protected by a towel or rub- 
ber apron thrown over the chest and lap. In 
most cases this application is to be, later, re- 
placed by a spray composed of glycerin (1 ounce) and water 
(4 ounces), or pure fluid cosmolin, vaselin, or albolene. 




Fig. 21.— U-shaped 
Nasal Tube. 




Fig. 22.— Dessak's Nas.a 



F. B. Kellogg recommends the following as a naso-pharyn- 
geal cleanser (Jour. Oph.,0tol,, and Lai'., Jan., 1891) : " A tube 
of soft rubber of the size of a No. 4 sound (French scale) is so 
perforated at the extremity as to throw five or six jets back upon 
itself at an angle of 45 degrees. This is attached to an Alpha 
or a fountain syringe, anointed with vaselin, and passed into 
the nose" and naso-pharynx. 

After the use of any watery solution, the patient should 



THERAPEUTICS OF CHRONIC RHINITIS. 37 

not blow the nose for at least fifteen minutes, lest some of the 
fluid be forced into the middle ear and give rise to otitis and its 
train of consequences. It is better, also, that he avoid going 
directly into the cold air. In the use of oil and glycerin, more 
is achieved than simple cleanliness, as the tissues are thereby 
medicated. If much temporary swelling exist, a 4-per-cent 
solution of cocaine may be used, or, better, a 1-per-cent men- 
thol-albolene spray. If the obstruction be more constant, it is 
usually well to make a groove through the most prominent 
point with a hot galvano-cautery knife-blade. (See " Hyper- 
trophic Rhinitis.") 



\> 



Fig. 23.— Post-Nasal Syringe. 

Internal remedies are to be prescribed for the constitutional 
changes, when discovered; otherwise, they should cover, as 
nearly as possible, the local symptoms and pathological altera- 
tions. 

Therapeutics. 

Alumina. — Catarrh of aged persons ; leucorrhcea alternating 
with nasal catarrh. Thick post-nasal mucus. 

Ammon. carb. — " The cavernous erectile tissue .... 
is the locality where this drug has its affinity of action. It will 
cure stoppage of the nostrils, acute or chronic ; in children this 
obstruction will prevent them from sleeping, causing nervous 
starting as soon as falling asleep." (J. A. Terry, Jour, of Oph., 
OtoJ., and Lar., April, 1890.) 

Calc. carb. — " An excessive redness of the mucous mem- 
brane of both nose and throat (not a congestion nor a chronic 
venous hyperaemia, but rather an evenly diffused, heightened 
color), and accompanied by excessive sensitiveness to local ap- 
plication, especially to stimulants, absorbents, and astringents." 
(The late Dr. C. L. Cleveland, ibid., January, 1890.) 



38 DISEASES OF THE NOSE AND THROAT. 

Calc. phos. — In chronic catarrhs in anaemic patients ; usu- 
ally mouth-breathers. Associated adenoid vegetations at the 
vault of the pharynx ; nasal tumors, especially mucous polypi. 
Frontal headache ; pressure on the bridge of the nose ; nasal 
lining pale and relaxed ; pharynx glazed. Imperfect digestion 
and nutrition. 

Cepa. — Nasal passages obstructed in a warm room ; can 
scarcely breathe ; must go into a cold room. Post-nasal drop- 
ping of clear, watery fluid (mere, cor., spigelia). 

Fer. iod. — Marked anaemia, malnutrition ; membrane re- 
laxed, and discharge of thin mucus ; also for hypertrophic and 
strumous rhinitis. 

Hepar. — Purulent, stringy, even bloody discharge. Catarrh 
from suppression of skin eruptions. Tonsils and anterior cer- 
vical glands hard and swelled. One of the best remedies where 
persons sneeze or have a tingling in the nose as soon as un- 
covered in the morning, or from drafts at any time. 

Hydrast. can. — Constant desire to blow the nose, which 
feels raw and excoriated. Discharge thick, tenacious, white, or 
yellow, both anteriorly and posteriorly. Scrofulous persons. 
Catarrhal frontal headache. Constipation. This remedy acts 
well in controlling the " cold-catching" tendency. 

Ignatia. — " A drug not generally recognized in chronic 
catarrh of the frontal sinuses and ethmoid cells, but I have seen 
most remarkable effects from it when the distress centres just 
across the nose, between the eyes. It relieves the present dis- 
tress of the patient and contributes largely to the cure of the 
chronic catarrh." (T. F. Allen, Chironian, November, 1889.) 

Natr. carb. — An excellent remedy for nasal catarrh, both 
hypertrophic and non-hypertrophic, when the external nose shows 
evidences of eruptions, erythema, acne, etc. The secretions 
from the nasal passages are hard and offensive or thick, yellow, 
or green. Anterior cervical glands enlarged. 

Natr. mur. — Hypersecretion of mucus with sneezing. Worse 
from exposure to fresh air. Occasional loss of smell. In the 



HYPERTROPHIC RHINITIS HYPERTROPHIC NASAL CATARRH. 39 

absence of clear indications for other drugs, this is one of the 
best remedies where persons draw mucus from the naso-pharynx 
in the morning - . 

Paris quad. — The late Dr. H. N. Martin recommended this 
remedy when there was a stuffed condition and fullness at the 
root of the nose ; constant hawking of tenacious, white, taste- 
less mucus, with dryness of the tongue and fauces on waking. 

Penthorum. — Continual feeling as if the nose were wet, but 
without discharge ; naso-pharynx feels raw, denuded ; nose and 
ears feel full. 

Puis. — Nasal discharge thick, muco-purulent, yellow or 
yellowish green, and bland, with loss of taste and smell. This 
remedy must be given at frequent intervals. The result is often 
disappointing unless there be mental or general symptoms to 
indicate the drug. It usually acts best in the very low or very 
high potencies, tincture or 200. 

Sepia. — Perhaps the most satisfactory remedy when there 
is a discharge of greenish lumps (asafcet., puis., psorin.) and 
pressure or gnawing in nasal bones ; uterine or menstrual dis- 
orders. 

Sticta. — Violent sneezing ; intense headache. Constant 
desire to blow the nose, although no discharge follows. Nasal 
lining so dry as to be painful ; dry scabs difficult to dislodge. 
" Stuffed feeling at root of nose." 

Therid. — Tough plugs; strumous patients; dull, heavy 
feeling in glabella; and fetid discharge from the nose, especially 
if complicated with bronchial and pulmonary catarrh. 

HYPERTROPHIC RHINITIS HYPERTROPHIC NASAL CATARRH. 

Etiology. — In consequence of the long continuance of 
chronic rhinitis, with persistent engorgement of the erectile 
tissue, the hypertrophic form may result. Although this is the 
usual origin of the affection, foreign substances and irritants, if 
brought constantly in contact with the Schneiderian membrane, 
may induce it. 



40 DISEASES OF THE NOSE AND THROAT. 

Pathology. — The pathological changes are totally different 
from the swelling in the chronic, non-hypertrophic form. In 
the disease under consideration, there is actual increase in the 
tissue-elements of the nasal passages, a deposit of connective 
tissue in the intra-vascular stratum. The epithelium is thick- 
ened, the mucosa proper increased in extent, and the deep layer 
of the mucous membrane (the submucosa) and the glandular 
elements are hypertrophied. Even the perichondrium and peri- 
osteum undergo the changes incident to such cell-proliferation, 
and it seems fair to presume that the cartilaginous and bony 
thickenings are sometimes a part of this process. 

Symptoms. — The chief symptom dependent upon hyper- 
trophic rhinitis is difficult nasal respiration. This varies from 
slight inconvenience to total abolition of the function. As a 
result of the consequent mouth-breathing, the air is not properly 
prepared for throat and pulmonary respiration, as it may be 
impure, cold, hot, dry, or overhumid, according to circumstances ; 
and pharyngitis (particularly follicular), laryngitis, tracheitis, 
and bronchitis may follow. Mouth-breathers are often dyspeptic 
and poorly nourished. Dental caries is a possible sequel. 
Continuing the symptoms, we may find thick, thin, scant, or 
profuse discharge ; the catarrhal process frequently extending to 
the pharynx and larynx, either as the result of continuity of 
tissue or the trickling of discharges from the posterior nasal 
region into the parts below. Obstruction of the nasal channels 
may so interfere with the entrance of odorous particles to the 
olfactory region that the sense of smell is obtunded or obliter- 
ated ; or, owing to the same obstruction, the accessory cavities 
may participate, giving rise to headache, dizziness, etc. In this 
connection, it is well to note the tendency of this disease to 
produce mental defects, especially loss of memory and inability 
to fix the attention upon any one subject (aprosexia). Chronic 
hypertrophy may superinduce polypi and other forms of nasal 
and post-nasal tumors. Defective hearing may follow extension 
of the catarrhal process to the Eustachian tubes, pressure of the 



HYPERTROPHIC RHINITIS HYPERTROPHIC NASAL CATARRH. 41 

hypertrophied tissue or new growths upon the mouths of the 
tubes, or interference with the proper action of the palato-tubal 
muscles in opening these channels to admit air for aeration of 
the tympani. Though a minor symptom, sneezing is sometimes a 
very annoying one. The voice is usually unnatural, " nasal," 
or even hoarse, and often practically destroyed for singing or 
public speaking. The so-called nasal quality is caused by 
hindrance to the normal vibration of the column of air within 
the nose. The hoarseness generally results from catarrhal im- 
plication of the larynx, although it may occur as one of the 
nasal reflexes. 

Scotoma, hyperemia of the fundus, conjunctivitis, contrac- 
tion of the field of vision, orbital neuralgia, and even glaucoma 
have been relieved by a reduction of the hypertrophic tissue. 

When looking into thejiasal cavities, one or both may be 
found encroached upon by thickened tissue. This is very 
unevenly distributed, giving an irregular appearance. In color, 
the hypertrophic tissue is a little darker than the normal mucous 
membrane. Although quite firm, it may be indented; but the 
parts at once recover, whereas in simple chronic rhinitis recovery 
is sluggish. 

S. Spicer (Ann. Univ. Med. Sci., 1888) calls "attention to 
the black, distended vein at the root of the nose as a striking 
physiognomical peculiarity of a large number of children, 
especially the feebler offspring of the poorer classes in large 
towns. This vein — the nasal arch — forms a transverse com- 
munication between the angular veins on either side. Associated 
with this condition is a neglected or intractable chronic catarrh 
of the nose and pharynx, often with swollen middle turbinated 
bodies and rhinorrhcea ; chronic congestion or hypertrophy of 
post-nasal mucosa or post-nasal vegetations are also present." 

Not infrequently external changes will be noted, in conse- 
quence of the intra-nasal alterations. These surface defects 
consist of acne, erythema, and, according to some writers, even 
erysipelas. Seiler (" Diseases of the Throat," third edition) 



42 DISEASES OF THE NOSE AND THROAT. 

says : " This irritation of the skin of the face is due, no doubt, 
to two causes, viz., first, reflex irritation of the vasomotor nerves 
of the skin, and, second, to the inability of the erectile tissue 
of the nose to act as a safety-valve in relieving the surplus 
blood-pressure in the capillaries of the skin of the face and 
nose." 

Examination of the naso-pharynx often discloses the pres- 
ence of extensive rough, mulberry hypertrophy of tire posterior 
ends of the lower turbinateds. This is sometimes so consider- 
able as to greatly hinder or obstruct nasal breathing. Adenoid 
vegetations are frequent. 




Fig. 24.— Posterior Hypertrophy of Middle and Inferior Turbinated 
Bodies, Both sides. (SajousJ 

Prognosis. — The prognosis is much more favorable now 
than it was a few years ago, owing to the great advancement in 
the surgical treatment of this affection. It is, even now, not 
usually good, as regards the final cure of the disease, but the 
relief is so considerable that it is frequently almost as satisfac- 
tory as a cure. So far as life is concerned, the prognosis is 
good, unless the process extend to the larynx, when, in addition 
to catarrh, there may be a veritable hypertrophy of this organ, 
so severe as to give rise to fatal dyspnoea, unless mechanically 
relieved. Habitual mouth-breathing may follow, or bronchitis 
or pneumonia result. The course of the disease is chronic, 
usually requiring years for its development. 



HYPERTROPHIC RHINITIS HYPERTROPHIC NASAL CATARRH. 43 

Treatment. — The treatment should generally be vigorous. 
The remedies are to be selected, first, according to the constitu- 
tional predisposition; second, with reference to the symptoms ; 
third, in accordance with the pathological condition. Local 
measures are. chiefly mechanical. In most instances, the 
primary result of treatment should be alleviation of the dif- 
ficulty in nasal respiration. While temporary relief may be 
afforded by the use of local remedies acting as cleansers and as 
stimulators of the relaxed tissues, their secondary effect may be 
to relax the tissues still further, and possibly to increase the 
hypertrophic process, thus augmenting the symptoms.. This 
does not apply to either menthol (2 per cent) or naphthalin (3 
per cent). If the soft parts alone be hypertrophied, some good 
may follow the use of pure soft-rubber tubes or gelatin bougies. 
The former are kept in the obstructed passage for one or two hours, 
morning and evening ; the latter, until they dissolve. It is to be 
remembered that this is a true increase, a connective-tissue deposit 
in the structures beneath the submucosa,an intra-vascular change, 
for which, when annoying symptoms arise, the only sure hope 
of radical improvement seems to lie in its partial, destruction. 
This may be accomplished by means of caustic acids, or, better 
still, by the galvano-cautery, saw, or drill. It is always better 
to treat the nasal fossae for a short time before using any form 
of cautery, as relief may follow mild measures. After any 
cauterant, the surface attacked should be sprayed with pyok- 
tanin (1 to 200) or vaselin, albolene, or other soothing substance. 
As yet, internal medicines play but a secondary part, but recent 
achievements give hope for the future of internal medication in 
hypertrophic nasal catarrh. 

The chief acids at the operator's disposal are nitric, glacial 
acetic, trichloracetic, monochloracetic, and chromic. Nitric 
acid should be used in the most experienced hands only, as its 
action cannot be easily limited, although it may be somewhat 
modified by strong solutions of bicarbonate of soda. When 
applied, it must be in very small quantities, and to only one 



44 DISEASES OF THE NOSE AND THROAT. 

small spot. A fine probe should have its tip covered with 
closely-wound absorbent cotton, which, after dipping in the 
acid, should have any excess of moisture pressed out of it 
before being used. A very fine glass rod or a probe dipped 



e.a.yapnall phila 
-Author's Nasal Probe. 



into melted glass is preferred by some. The action of the acid 
is very prompt and quite painful. A pledget of absorbent 
cotton, wet with a 4- to 10- per-cent solution of cocaine hydro- 
chlorate should be kept in contact with the part for five or ten 



Fig. 26.— Sajoxjs' Guarded Acid Applicai 



minutes prior to the acid application. For a few hours the 
nose will swell considerably and be very sore, but this will 
decrease on the second or third day. On account of the intense 
reaction, the application should not be repeated for two weeks, 



J 



Fig. 27.— Author's Guarded Post-Xasal Acid Applicator. 

and then on the spot first attacked, lest too much of the mucosa 
be destroyed, superinducing loss of function or even atrophy. 
The acid application results in the formation of a groove or 
depression, contraction of which causes a decrease in the sur- 

e.a.varnall phila. 
Fig. 28.— Jarvis' Snare, as Modified by Sajous. 

rounding hypertrophy. In the use of glacial acetic acid there 
is much more safety, although its action is slower, requiring 
several weeks to accomplish as much as would one application 
of the nitric acid. Its effect is not very severe, and may be 



HYPERTROPHIC RHINITIS HYPERTROPHIC NASAL CATARRH. 45 

modified, when desired, by the use of oil or strong bicarbonate 
of soda. If necessary, the glacial acetic acid may be re- 
peated every week. The monochloracetic and the trichlor- 
acetic acids are preferable to either of the foregoing. While 
they have much of the brilliant action of the nitric acid, their 
force may be regulated by the prompt use of oil. The best 
application, however, is chromic acid ; its action is slow, and it 
is necessary to repeat it every five or six days for from two to 
many weeks, depending upon the amount of hypertrophy. It 
should be applied to one part until the end in view has been 
attained. The crystals may be dissolved in a little water and 



applied by means of a cottoned probe, or the pure crystals may 
be fused on the end of a heated probe and placed upon the 
desired area. In some cases 1 have seen marked clonic spasms 
of the tissue covering the lower posterior portion of the trian- 
gular cartilage follow the use of the acid. These spasms begin 




Fig. 30— Galvano-Catjteky Handle and Snake. 

about one minute after the contact of the chromic acid, and 
continue for five or six minutes. Caution: Never use glycerin 
before making an application of chromic acid. 

The galvano-cautery is usually the most satisfactory method 
of reducing nasal hypertrophy. With it there is no difficulty 
in limiting the amount of destruction ; almost no reaction 
follows; the application can be repeated every three or four 
days, or as soon as the eschar has separated ; and, if the point 
be heated to a bright-cherry color, there is scarcely any pain. 
In using the galvano-cautery, a thin, flat knife, about two milli- 
metres broad, is the most satisfactory. 



46 DISEASES OF THE NOSE AND THROAT. 

When it becomes advisable to reduce an hypertrophy 
of the middle turbinated, the snare or the electric trephine 
(Whiting) is to be preferred to the gaivano-cautery or caustic, 
which should not be used freely, lest meningitis occur or 
amblyopia follow. In either operation care should be exercised 
not to injure the septal (olfactory) surface of the turbinated 
membrane. 

Septal hypertrophies are often best treated with the saw, 
drill, snare, knife, or chisel. (See " Exostoses.") 

In all efforts at the destruction of hypertrophic tissue, care 
should be exercised not to attack more than is essential to the 
accomplishment of the object desired; otherwise, healthy tissue 
will be sacrificed, possibly resulting in the formation of atrophic 
catarrh, ozama, perichondritis, or caries. 

Local applications, such as suggested under " Chronic 
Rhinitis," are not to be neglected, as they serve to keep the 
membrane in a cleaner, healthier condition than where they are 
withheld. If the hearing be defective, it may be necessary to 
place the patient under a strict course of aural treatment, in- 
cluding medicines, care of the nasal and post-nasal region, infla- 
tion of the middle ear, and massage of the membrana tympani. 
As the nasal defect is often the original affection, its cure may 
result in the complete relief of the secondary disorder. The 
palatine muscles may require electrical treatment, as they are 
often palsied from lack of use or from the pressure of tumors 
or hypertrophies. If tumors be present, they are to be treated 
as described under the appropriate heading, and when the 
larynx is involved it is to be cared for according to the 
indications found under "Catarrhal Laryngitis" or "Chronic 
Hypertrophic Laryngitis." 

As scrofula is a frequent condition in persons suffering 
from hypertrophic rhinitis, ars. iod., calc. carb., hepar, iodine, 
silica, and similar remedies are often indicated. When syphilis 
acts as a predisponent or an excitant, kali iod., mere, mere, 
iod. rub., mere. iod. cum kali iod., phytol., etc., will aid. 



ATROPHIC NASAL CATARRH. 47 

Therapeutics. 

Alumen usta. — Hypertrophic catarrh ; frequent bleeding ; 
discharge of thick, tenacious mucus. Polypoid granulations, 
which bleed easily. 

Ammon. chlor. — This is often called for in the absence of 
well-defined indications. Hypertrophy, chiefly of the septum. 

Ars. iod. — Irregular hypertrophy and granulation of the 
soft parts. Thick yellow discharge ; enlarged tonsils and other 
glands. 

Carbo veg. — Spongy hypertrophy, especially if associated 
with epistaxis, particularly in elderly persons. 

Fer. iod. — Associated with follicular pharyngitis and ade- 
noid vegetations (fer. phos. and sang. nit.). 

Merc. sol. — Hypertrophy, with the characteristic symptoms 
given under acute and chronic catarrhal rhinitis. 

Silica. — With purulent or corrosive and thin secretions. 
Ulceration. Symptoms worse in the morning, when the voice 
is husky. 

ATROPHIC NASAL CATARRH MUCO-PURULENT DRY RHINITIS 

OZ^NA. 

Etiology. — Atrophic catarrh has an existence independent 
of ozaena, but, as the latter (fetid odor of special character) is 
such a frequent accompaniment to atrophic cases of long stand- 
ing, I think it best to consider them together. As muco-puru- 
lent dry rhinitis is a result of atrophy, it must be distinguished 
from simple dry rhinitis as found in chronic nasal catarrh. 

It is generally stated that the most frequent cause of 
atrophic nasal catarrh is hypertrophic rhinitis, which undergoes 
atrophy as the result of pressure of the hypertrophic tissue 
upon the underlying structures ; some, however, deny such 
origin. The glandular organs usually suffer first, but finally 
the submucous structures, including the venous sinuses, yield, 
the blood-supply and nerve-stimulus are diminished, the sense 
of smell becomes blunted, and the nutrition of the part im- 



48 DISEASES OF THE NOSE AND THROAT. 

paired. The mucous membrane is thinned so that, in many 
instances, the turbinated bones seem atrophied and stand out in 
bold relief, a mere skeleton of their normal condition. As 
another cause should be mentioned chronic purulent rhinitis 
of children (which see). Several instances have come under 
my notice in which no atrophic symptoms existed previous to a 
severe "grip" seizure; some cases seem to be atrophic from their 
inception, and some take on atrophy as a result of various irri- 
tants, including dust, filings, snuff, tobacco-smoke, etc. The 
various exanthemata are doubtful etiological factors. Arrest in 
the development or growth of the structures going to form the 
normal nasal fossae may produce atrophy. Finally, traumatism, 
the long retention of a foreign body in the nose, or the continuous 
contact of two mucous surfaces may induce it. Syphilis, scrofula, 
and tuberculosis should be excluded as etiological factors. 

It must not be understood that all or even the majority of 
cases of hypertrophy undergo the atrophic process ; neither 
should it be thought that even a majority of atrophic rhinites 
are ozsenous, although many are. 

Those most frequently affected are in rather poor health, 
overworked, and illy nourished. Persons after middle life are 
rarely attacked, puberty seeming to be the most prolific period 
for its development. 

Pathology. — The pathological changes in atrophic rhinitis 
are numerous. There is a decrease in the epithelial covering, 
and Volkmann has found that the cylindrical epithelium is trans- 
formed into that of the pavement variety, and of the interme- 
diate, or transitional, stage. The mucosa is devoid of glands 
and transformed into either a granulation or a cicatricial tissue, 
ten or twelve layers thick of pavement epithelium, the upper 
layer analogous to the epidermis. As this layer increases, a 
mass of dead epithelial cells accumulates and becomes a putre- 
factive centre of infection. The cause of the ozsenous odor, 
when present, has been variously attributed to the retention of 
discharges in the accessory cavities and to the presence of micro- 



ATROPHIC NASAL CATARRH. 49 

organisms, especially the diplococcus of Lowenberg, who con- 
siders it the cause of special fermentation, upon which the odor 
depends. The ozsenous crusts are composed of mucus, pus, 
epithelium, often fibrin and serum, and mucin ; when expelled 
there remains a moist, creamy discharge. If the accessory cavi- 
ties be implicated the degree of offensiveness is greater than 
otherwise, and is often almost unendurable. Upon the removal 
of the accumulations, it may be seen that there exists a degree 
of erosion, but true ulceration does not occur in uncomplicated 
cases. The secretions are not stopped, as the name " dry " would 
imply, but are of such a nature as to dry rapidly and formscabs 
or crusts on the mucosa. These may be green, yellow, brown, 
or bloody. 

Symptoms. — The symptoms are almost the reverse of those 
found in the hypertrophic form. Nasal respiration is free ; the 
discharge, either anteriorly or posteriorly, is slight, except as 
the crusts are dislodged ; there is little sneezing ; the accessory 
cavities may be implicated ; pharyngitis sicca (atrophic naso- 
pharyngeal catarrh) usually follows, and may lead to catarrh, 
even ozsena, of the larynx and trachea. During the early stage, 
the patient is usually aware of an annoying, faint, stale odor 
from his nose ; but later the sense of smell becomes so blunted 
that, even after a truly offensive ozsena is present, he is not con- 
scious of his obnoxiousness. The accumulation of dry discharge 
gives rise to a full, disagreeable, often painful, sensation, which 
induces the patient to bore at the nose ; at other times the 
upper lip is drawn down or the nostrils are dilated by muscular 
action, each for the purpose of relieving the drawn, dry, and 
tense feeling. The scabs are generally difficult to dislodge by 
blowing, as the nasal passages are so spacious that the air- 
current has no especial effect upon them. They vary in color, 
as stated, and may be small flakes or so large as to form com- 
plete casts of the portion covered. Epistaxis may occur from 
the erosions, and from the habit of picking the nose the carti- 
laginous septum may be perforated. The general health may 



50 DISEASES OF THE NOSE AND THROAT. 

suffer and indigestion result from the passage of the purulent dis- 
charges into the stomach ; menstrual disorders are frequent. In 
many instances the nose is small, the alee and bridge broad, and 
the nose apparently sunken into the face, — the so-callad saddle- 
back. 

Inspection of the anterior nasal canals reveals a character- 
istic picture : the greater portion of the membrane may be seen 
covered with the greenish-gray crusts referred to, which, when 
removed, reveal a pale and thin membrane, with occasional 
erosions. The turbinated bones usually lose their scroll-like 
form and atrophy, making one or both of the nasal fossae very 
spacious. The shrunken appearance of the lower turbinateds 
is due either to atrophy or to collapse (MacDonald) of the erectile 
tissue. Occasionally, the turbinated bones have entirely dis- 
appeared from anterior view, but posterior rhinoscopy gives less 
evidence of change. 

In looking back into the deeper portion of the nasal cavi- 
ties, it is not usually difficult to see the dry, glistening pharyn- 
geal wall, the motion of the muscles, the prominences, or even 
the mouths, of the Eustachian tubes. The pharynx and naso- 
pharynx are generally dry, glazed, glistening from the extension 
of the process (pharyngitis sicca). 

Prognosis. — The prognosis is comparatively good, as a 
rule ; the absolutely hopeless outlook of a few years ago is a 
thing of the past. Some cases recover, so far as practical com- 
fort is concerned ; collapsed tissue will usually refill, but the 
atrophic loss can never be completely repaired, hence an abso- 
lute cure is impossible. Usually, little can be accomplished 
under three months, although decided comfort may follow the 
second week's treatment. Entire comfort may not be secured 
for a year or longer. Life is rarely curtailed by the existence 
of atrophic catarrh, but it is to be constantly borne in mind 
that at any time an atrophic rhinitis may become an ozaena of 
the worst form. 

Treatment. — The treatment is to be based upon the consti- 



ATROPHIC NASAL CATARRH. 51 

tutional changes and symptoms, when present. Among the 
local measures, the first to note is cleanliness, as already ex- 
pressed. Much force should not be used in removing the 
crusts. This precaution is too often neglected, thereby causing 
unnecessary injury. It may be added that a little irritation is 
often beneficial, as it serves to institute a better reaction, and 
may give new life to the glandular and muscular structures. 
The best solution for cleansing the membrane is salt, gr. x ; 
bicarbonate of soda, gr. x; warm water, Siv. It is best employed 
by means of the post-nasal syringe. It is well not to use more 
than three or four syringefuls at one sitting, two or three times 
a day. The same is true if the patient snuff the solution out of 
the hand or from a U-shaped tube. The nasal douche is to be 
discouraged, on account of its liability to cause disease of the 
frontal and ethmoidal cells, antra of High more, and middle ears. 
The precaution neither to blow the nose nor to go into the 
cold air for fifteen minutes after the use of aqueous solutions 
in the nose should be enjoined here, as elsewhere. 

In a large number of cases the cleansing can best be accom- 
plished with a spray of fluid cosmolin, vaselin, or albolene. 
After the membrane is once freed, this spray should be repeated, 
by the patient, five or six times daily, for the purpose of keep- 
ing the parts thoroughly lubricated. It is sometimes well to 
medicate the oil with the remedy internally indicated. Dr. 
William R. King, of Washington, told me that he had obtained 
much satisfaction from a spray of a weak solution of the extract 
of green plantain in fluid albolene. 

If, after a few days, these means fail to dislodge the scabs, 
they should be carefully loosened at their edges with a fine, 
cotton-covered probe, and removed with angular forceps or post- 
nasal syringe, or by blowing. When thoroughly cleansed, the 
underlying abrasions will heal more promptly if boric acid, 
iodol, or aristol be insufflated upon them. In very offensive 
cases, a few crystals of permanganate of potassium, or a drop of 
menthol, creolin, or carbolic acid, should be added to the 



52 DISEASES OF THE NOSE AND THROAT. 

cleansing fluid. A 20-per-cent aqueous solution of calendula 

is at times effective as a spray or application. 

" Menthol in oily solution (benzoinol), 10 per cent, I find 

to be an excellent application in dry conditions of the mucosa. 

Atrophic rhinitis, pharyngitis, laryngitis, and ozsena are all 

benefited to a great degree." (Dr. Malcolm Leal.) 

Ichthyol (5 per cent), in keroline, daily applied to the 
cleansed nasal lining, and a 10-per- 
cent vaselin solution of the above 
sprayed into the nose four or five 
times a day, have proved highly 
gratifying. Permanganate of potas- 
sium, thoroughly triturated with 
starch or sugar (1 to 10), is an ex- 

Angulae Forceps. _. . . 

cellent insufflation for the cleansed 
surface ; and camphorated naphthol in albolene has strong- 
advocates. 

No one application should be continued very long, as the 
diseased structures become non-responsive after a time. 

When the reaction is sluggish and the secretions remain 
tenacious, in defiance of treatment, 1 have for some years been 
using loosely-rolled pledgets of absorbent cotton, saturated with 





Fig. 32.— Insufflator. 



pure glycerin {Trans. Horn. Med. Soc. State of Pa., 1891, and 
Jour, of Oph., Otol., and Lar.. January, 1892), and find that 
they act very promptly in establishing a mucous flow, in loosen- 
ing the crusts, in modifying the odor, and in giving relief to the 
annoying subjective symptoms. One side is treated at a time ; 
the pledget need be kept in position but a few minutes, or until 
a profuse watery flow is established, when all can be readily 



THERAPEUTICS OF ATROPHIC NASAL CATARRH. 53 

blown into the handkerchief. The patient may repeat the pro- 
cedure two or three times daily. This, together with the kero- 
line-ichthyol or the menthol spray, proves very grateful to most 
patients. Aristol (iodide of thymol) often acts promptly in 
destroying the odor as well as in healing erosions. It may 
be insufflated pure, or applied (Lowenstein) as a collodion, — 1 
part of the iodide to 10 of flexible collodion. A spray of per- 
oxide of hydrogen (15-volume) is a favorite with many. Light 
searing with the almost white galvano-cautery point sometimes 
aids the stimulating process, but much harm may result from 
the free use of this instrument. 

Galvanism often acts beneficially in restoring activity to 
the vasomotor nerves and mucous membrane. The negative 
pole, covered with wet absorbent cotton or sponge and con- 
ducting a very weak current (four to six milliamperes), is applied 
to the nasal mucous membrane, the positive pole resting on the 
forehead. Ten- to fifteen- minute applications may be repeated 
every two or three days. 

As a rule, co-existing disease of the accessory cavities will 
gradually heal, as the result of the treatment already mapped 
out ; but, should it not, direct treatment may become necessary. 
(See "Diseases of the Accessory Cavities.") This, however, is an 
extreme view of the case, and one that will rarely require fulfill- 
ment if the outlets of these spaces be kept free and the remedies 
given according to indications or well-attested experience. De- 
layed, irregular, or absent menstruation should receive a due 
amount of medicinal, hygienic, and dietetic care. 

Therapeutics. 

Alumina. — Snapping in the ears when eating or swallow- 
ing; aggravation of nasal symptoms from the slightest exposure; 
naso-pharyngeal symptoms alternate with leucorrhoea. Nasal 
discharge thick, greenish yellow, and bloody. Anosmia; mind 
sluggish ; inability to do mental work ; aprosexia. 

Argent, nit. — " Bloody and purulent nasal discharge ; 
ulcers, covered with yellow crusts." (Morse, " Nasal Catarrh.") 



54 DISEASES OF THE NOSE AND THROAT. 

Ars. iod. — Nose swelled ; profuse, thick, yellow discharge ; 
burning in the larynx; ozsena in strumous subjects; enlarged 
tonsils ; hypertrophied naso-pharyngeal membrane. 

Aurum met. — Caries of nasal bones ; nasal bones sore to 
touch ; fetid discharge ; nostrils ulcerated. Mercurial, scrofu- 
lous, and syphilitic complications ; nasal obstruction. Charge 
(" Trait. Homoeo. des Maladies des Organes de la Respiration ") 
says that, from personal observation, he considers kali bi. a great 
aid in completing the cure begun by aurum met. 

Aurum mur. — When the nasal passages are filled with 
offensive, greenish-yellow, or bloody plugs ; scrofulous, mer- 
curial, and syphilitic ozsena. Small, painful ulcers in the nasal 
passages ; bloody discharge ; headache ; loss of smell. Pains 
relieved by keeping the head warm. 

Calc. carb. — Thick, dirty-looking, fetid, purulent discharge, 
which corrodes the lip ; soreness or ulceration of the septum. 
Swelling externally and internally ; frequent and profuse epis- 
taxis and hoarseness, especially in the morning. Scrofulous 
subjects. 

Cuprum. — Frontal pain, worse over the left eye and at the 
root of the nose, aggravated by motion ; involvement of the 
frontal cells. Loss of smell and impaired taste. 

Elaps. — " Partial stoppage and stuffiness high up in the 
nostrils, with dull aching to forehead ; worse in wet weather. 
Occasionallv, bad smell from the nose ; offensive discharge ; 
posterior wall of throat covered with a dry, greenish-yellow 
scab, wrinkled and fissured, extending up to nose ; occasional 
nose-bleed ; pain from root of nose to ears on swallowing ; 
sneezing at night; sense of smell gone; profuse and dark 
catamenia." (Raue, "Special Pathol, and Therap. Hints.") 

Graph. — Takes cold easily ; ozaena much more fetid during 
menses. Tough, lumpy, bloody, or yellow, fetid discharge ; smell 
as from a purulent coryza ; nostrils ulcerated ; eczema behind ears. 

Kali bi. — Thick, offensive, lumpy or ropy, dark-green, often 
blood-stained discharge from nose and throat. Involvement of 



THERAPEUTICS OF ATROPHIC NASAL CATARRH. 55 

the frontal sinuses. Nasal passages painfully dry. Naso- 
pharyngeal catarrh, with discharge of a similar character. 
Sycotic constitution. (See aurum met.) 

Kali iod. — After the abuse of mercury. Greenish-yellow, 
excoriating discharge ; throbbing and burning in nose and fore- 
head. Enlarged submaxillary glands ; associated otorrhcea. 

Merc. cor. — Ozsena; discharge glue-like, often drying in 
naso-pharynx ; nasal fossae raw and smarting. 

Petrol. — Scabs and muco-pus; nose sore and nostrils cracked 
(graph.) ; muco-pus in the naso-pharynx. Internally and locally. 

Phytol. — Marked and persistent excoriation of nostrils and 
lip ; puriform discharge. This is one of the most potent reme- 
dies where there is a syphilitic history. 

Psorin. 200 x. — Intractable cases of scrofulous origin. 
The ichorous discharge and great fcetor are the key-notes of 
this remedy. 

Puis. — Thick, yellow, or green and fetid discharge, chang- 
ing color and consistence frequently ; loss of taste and smell. 
Mild, timid, yielding persons, especially if associated with men- 
strual difficulties, — flow scanty, late, and pale. 

Sepia. — To me, this is one of the most useful remedies in 
atrophic catarrh, and when the following symptoms are present I 
have no doubt of the improvement : yellow or greenish crusts 
or plugs discharged through the anterior nares, and a gnawing 
pain or pressure at the bridge of the nose. 

Silica. — " Ozaena when the affection is seated in the sub- 
mucous connective tissue or periosteum. Painful, chronic dry- 
ness of nose, or inveterate ulceration, producing acrid corroding 
discharge ; herpetic eruption around nostrils and lips. Itching 
of tip of nose." (Boericke & Dewey.) Secretion purulent, 
thick or thin, and excoriating to the nose. Throat dry and 
painful ; thick, green, fetid, post-nasal discharge. 

Sulphur. — Chiefly as an intercurrent, but sometimes, also, 
if the nose be very dry, with a stiff, parchment-like sensation or 
a discharge of thick, bloody mucus. 



56 DISEASES OF THE NOSE AND THROAT. 

Therid. — Discharge yellow or greenish yellow, crusty or 
thick, and offensive ; but particularly if the crusts be drawn 
into the throat and expectorated. Dr. A. Korndoerfer's chief 
symptoms for the use of this remedy are : offensive discharge, 
either thick or thin ; headache ; and a feeling of fullness or 
pressure at the bridge of the nose. 

Thuja. — Copious, thick, green, purulent, or bloody dis- 
charge; swelling and hardness of the alee nasi. Thick, tena- 
cious, hard crusts form in the olfactory tract especially. 



CHAPTER IV. 

Various Diseases of the Nasal Passages. 

rhino-scleroma scleroma respiratorium. 

Although never reported as occurring in the United States 
of America, yet it seems advisable to refer briefly to this Euro- 
pean and South American affection, whose home appears to be 
Poland. From recent research, there exists but little doubt that 
rhino-scleroma has a place in nosology independent of syphilis, 
scrofula, lupus, tuberculosis, or traumatism, upon which many 
believe it depends. 

Etiology. — It is exceedingly rare, and its cause or causes 
are obscure ; although Frisch has discovered a bacterium simi- 
lar to Friedlander's pneumococcus, which is considered by some 
to be its progenitor. Stepanow (Monatsch, fur Ohrenhelllc, 
No. I, 1889) has proved (by inoculation) that it is infectious, 
and that Frisch's microbes are its cause. 

Pathology. — Its pathological changes are in the direction 
of chronic inflammation, cicatricial changes, and small-celled 
hypertrophies of the entire thickness of the invaded skin and 
mucous membrane. This soon results in shriveling of the under- 
lying connective-tissue elements. Kaposi {hdevnat. kiln. Rund- 
schau, 1891) says that it seems to be a tumor placed under the 
corium, like a piece of ivory. It never ulcerates, and does not 
bleed when cut. Microscopically, it resembles a small-celled 
sarcoma. 

The alae nasi and septum are the favorite starting-points 
for rhino-scleroma, although it may first appear on the pharynx, 
soft palate, naso-pharynx, or larynx. The hypertrophy usually 
spreads very slowly to surrounding parts; it may involve the 
lips, cheeks, gums, and all of the upper respiratory tract. 

(57) 



58 DISEASES OF THE NOSE AND THROAT. 

The diseased tissue is somewhat elevated, flat, and sharply 
defined. The nodes or patches are very hard, and are quite 
painful upon pressure. They may be pale, resemble a glisten- 
ing cicatrix, or be similar in color to the surrounding structures 
True ulceration never occurs, although there may be superficial 
erosion. Removal is speedily followed by return. 

Symjrfoms. — The symptoms are local and consist of dis- 
figurement; diminution of the nasal, pharyngeal, and oral cavi- 
ties; difficult respiration; and difficult and painful deglutition. 
When the larynx participates, hoarseness and dyspnoea may 
follow. 

The disease is frequently mistaken for some of the constitu- 
tional disorders named, but the continued hardness of the non- 
ulcerating nodes will serve to differentiate the affection after a 
lapse of some months. It is always chronic, and may last from 
fifteen to twenty-five years. 

Prognosis. — The prognosis is unfavorable, so far as present- 
known measures are concerned, and laryngeal dyspnoea may 
prove fatal unless relieved by intubation or bronchotomy. 

Treatment by remedies has proved futile, but local caustics, 
including the galvano-cautery, have been successful in tempora- 
rily reducing the hypertrophy. Dilatation seems to have proved 
beneficial ; for this purpose catgut, laminaria, tubes, etc., have 
been used. Pathologically, it would seem that the local and 
internal use of thuja, graphites, or calendula should prove 
beneficial. 

CHRONIC BLENNORRHCEA OF THE UPPER AIR-PASSAGES. 
(STOERK.) 

This is an exceedingly rare condition, even in Europe ; 
although the Polish Jews have furnished numerous cases. In 
this country it is almost unknown. It consists of a chronic, 
profuse, muco-purulent or purulent, and often offensive dis- 
charge from the nose, pharynx, larynx, and trachea, unattended 
by ulceration of the mucous membrane. The nose and pharynx 



ACUTE PURULENT CORYZA OF CHILDREN MALIGNANT RHINITIS. 59 

do not seem to undergo any special structural alteration, but the 
larynx is sometimes stenosed, — the result of plastic adhesions 
between the vocal bands, or of lateral, infra-glottic, hyper- 
trophied tissue. 

Prognosis. — The prognosis is unfavorable ; the voice may 
be permanently destroyed, or stenosis prove fatal. 

Treatment. — The treatment should be internal, local, and 
sometimes surgical. Local cleanliness and antisepsis are neces- 
sary, and tracheotomy and dilatation are frequently demanded. 
Internally, the remedies noted under " Atrophic Rhinitis" should 
prove beneficial. 

ACUTE PURULENT CORYZA OF CHILDREN MALIGNANT RHINITIS. 

This unusual condition consists of a purulent secretion 
from the nasal passages of very young children, and a thicken- 
ing and softening of the mucous lining, into which there is a 
considerable extravasation of blood. Frequently associated with 
it are ulceration and sloughing. The bones and cartilages 
sometimes participate in the destructive process, resulting in 
perforation of the nasal septum and partial or complete loss of 
the turbinated bones. Pseudomembranes may form, in appear- 
ance not unlike those of diphtheria, but are thinner and not so 
intimately connected with the underlying structures; the con- 
dition may finally undergo a true diphtheritic transformation. 

Etiology. — The causes of malignant rhinitis are those of 
infection. As with ophthalmia neonatorum, the source of in- 
fection is nearly always the vagina during parturition. The 
nasal disorder manifests itself in from two days to two weeks after 
inoculation. This disease should not be confused with congenital 
syphilis, with which it is sometimes associated. Diphtheria is 
its closest ally. 

Symptoms. — Symptomatically, the disease is usually well 
outlined. Sneezing is one of the first indications, but a dis- 
colored, even bloody discharge soon follows, which, in a few 
hours, or at most a couple of days, becomes purulent. Later, 



60 DISEASES OF THE NOSE AND THROAT. 

pseudomembrane may develop. Almost from the onset there is 
some defect in nasal respiration ; this usually soon amounts to 
complete stenosis. Malaise is an early symptom, and fever soon 
reaches 101° to 104° F. Prostration is great, and the struggle 
for breath is often agonizing. 

Prognosis. — The prognosis should be guarded; some au- 
thorities place the mortality at two-thirds, others at one-half, 
while Nichol ("The Larynx and Trachea in Childhood") gives 
a more favorable estimate, and from his experience it would 
seem that a large percentage of the otherwise doomed half 
should be saved. In favorable cases the symptoms gradually 
subside, leaving the nasal passages more or less clear. Inani- 
tion due to inability to nurse is frequently followed by coma and 




Vm. SI-Dk Villbis' Atomizer. 



death. Other things equal, the younger the child, the graver 
the prognosis. 

Treatment. — The treatment is chiefly medicinal, but its im- 
portant aid is cleanliness. For the latter purpose, it may be 
advisable to use a spray of an aqueous solution of permanganate 
of potassium, 1 grain to 1 ounce; or peroxide of hydrogen, 4 
drachms to 1 ounce. This is to be repeated as soon as nasal 
respiration becomes labored. In the absence of a spray, the 
nose may be gently syringed with the same solutions. During 
these manipulations the child should be held upright, in order 
to prevent the entrance of the liquid into the larynx. For the 
purpose of removing tenacious discharge, coiled blotting-paper 
or absorbent cotton should be passed into the nose. If the 



CHRONIC PURULENT RHINITIS OF CHILDREN. 61 

child be unable to breathe while nursing, a small rubber tube 
should be carefully passed through one inferior nasal meatus, 
well into the pharynx, thus rendering respiration and nursing 
less difficult. 

The internal remedies which acted best in the cases recorded 
by Nichol were apis, argent, nit., and nitr. ac. Ar's., chin, ars., 
fer. iod., iodine, and sang. can. are equally valuable. 

CHRONIC PURULENT RHINITIS OF CHILDREN. 

Etiology. — This affection has been looked upon, by some, 
as a sequel of syphilis, scrofula, and tuberculosis, but these com- 
plications are found under their appropriate headings; that 
which is here referred to is an independent disease. It is not 
the result of acute purulent rhinitis of children, as that disease 
is of short duration and speedily terminates either in resolution 
or death. Its causes are obscure, but are, no doubt, the result 
of repeated " colds " and catarrhs, which finally occasion some 
epithelial destruction, resulting in a purulent catarrh. 

Pathology. — Chronic purulent rhinitis of children consists 
of a muco-purulent, followed by a purulent, yellow discharge 
from both nasal passages. There is no involvement of the deeper 
structures of the Schneiderian membrane, the epithelium alone 
being affected ; the ciliae are early lost, and the greater part of 
the epithelium is destroyed. The pathological process does not 
cause ulceration, and never attacks the bones or cartilages. 

Symptoms. — There is rarely pain or soreness, and no con- 
stitutional symptoms occur unless the stomach be disordered from 
entrance of the purulent material. Nasal respiration is rarely 
obstructed, except by dry discharge during sleep. There is no 
decided fcetor during the fluent period. The patient is subject to 
acute exacerbations, but is not usually so susceptible as are other 
children ; the loss of the ciliae or epithelium appearing to render 
the mucosa less sensitive to the influences which induce acute 
coryza. If the nasal passages be examined, they will be found 
covered with a yellowish secretion, which, when wiped away, 



62 DISEASES OF THE NOSE AND THROAT. 

leaves the membrane in an apparently healthy condition. The 
pharynx and choanee are generally coated with a thick, stringy, 
or gluey discharge. The patient is usually in robust health, 
and shows no evidence of a blood taint. 

Prognosis. — The prognosis is good ; with care, all cases 
will improve and many be cured. If the disease continue to the 
age of puberty, it usually subsides; although atrophy may 
follow and occasion a most intense ozsena. 

Treatment. — The treatment, though chiefly medicinal, is 
to be accompanied by local cleansings, as suggested under 
"Atrophic Rhinitis." Hygiene and diet are of importance. 
The internal remedies will be found under " Chronic Nasal 
Catarrh" and "Atropine Rhinitis." 

PHLEGMONOUS RHINITIS. 

Etiology. — This affection is to be classed among the very 
rare diseases of the nose. It is usually due to infection during 
the course of a rhinitis, but may result from one of the continued 
fevers, from erysipelas, or be a manifestation of general blood- 
poison. Its course is short, frequently only four or five days, 
although the acute symptoms may last ten or twelve, and result 
in abscess, caries, necrosis, etc. The principal changes are those 
characteristic of phlegmonous affections elsewhere. 

Symptoms. — Symptomatically, there are obstructed nasal 
breathing and pain in the nose, head, or malar region ; the 
latter two are due to involvement of the accessory cavities. 
There is, usually, free discharge from the nose, some elevation of 
temperature, acceleration of the pulse frequence, malaise, and 
prostration. The septum is, as a rule, much thickened, and 
may even press against the turbinateds, but the latter are rarely 
phlegmonous. The mucosa is dull, relaxed, flabby, and as soon 
as pus is formed a boggy sensation is imparted to the examining 
finger or probe. 

Prognosis. — The prognosis is usually good, although the 
septum may be perforated, leading to deformity ; or chronic 
abscess may give rise to caries or necrosis. 



GLANDERS FARCY. 63 

Treatment. — The treatment consists of the early applica- 
tion of cold compresses to the nasal region and evacuation of the 
abscess, should one form ; but especially of the administration 
of the appropriate internal remedy. In the early stage, ars., 
china, hepar, kali iod., or mercury may be indicated; when the 
disease is fully established, hepar or iodine ; when the presence 
of pus is becoming evident, hepar or mere. ; and for the sequelae, 
hepar, kali mur., puis., or silica. 

GLANDERS — FARCY. 

Etiology. — Glanders is a very unusual disease in man. It 
is directly the result of inoculation either from horses or from 
man ; its only source of origin is contagion through a specific 
virus. It is introduced by contact with a mucous surface or a 
cutaneous abrasion. The disease usually occurs in males, owing 
to their greater association with animals. It may be either acute 
or chronic ; but it has the peculiarity that, although the acute 
form may result from the chronic, the latter, it is said, is never 
the result of the former. 

Although glanders and farcy are essentially the same dis- 
ease, since one may contract glanders from a farcy patient, or 
vice versa, their manifestations are not strictly the same ; the 
former attacks chiefly the mucous membrane and its glandular 
structure ; the latter shows itself mainly in the lymphatics. 

Progress. — The progress of the chronic form of the affec- 
tion is slow, and may last for many months, or its ravages 
may show themselves in the form of marasmus, which may 
prove fatal after many years of suffering. In the acute affec- 
tion, the disease runs a very rapid course, — that is, from seven 
to twenty-one days. When the acute form follows the chronic, 
it is more rapid in its course than when the result of direct 
inoculation. 

Pathology. — Pathologically, it is a tuberculous affection. 
The glands are greatly involved, the mucosa undergoes ulcera- 
tion, and the bones and cartilages may be destroyed. 



64 DISEASES OF THE NOSE AND THROAT. 

Symptoms. — The symptoms of the chronic variety are 
chiefly those of great prostration, with some involvement of the 
throat and nose, in which there are superficial ulcers, with de- 
cided hypertrophy of the glandular elements. The mucous 
membrane appears dry and of a dull-red color. 

The acute form is usually ushered in with chilliness and 
high fever, aching in the back and in the muscles and tendons 
about the larger joints. When the lymphatics are extensively 
involved they are, at an early period, very large and tender ; 
later, suppuration may occur. If the mucous structures be the 
first to suffer, there will be discharge from the nose, sneezing, 
impaired respiration, and epistaxis. The pharynx may feel 
obstructed and well-marked infiltration appear; this may extend 
to the larynx and result in oedema. Although the epiglottis 
usually bears the force of the poison, the glottis may be en- 
croached upon from extension of the process to the tissues 
about it. The discharge through the nostrils soon gives rise to 
an erysipelatous eruption of the lips, face, and surrounding 
parts ; this soon forms bullae, which rupture and dry. When 
the crusts fall off, the underlying structure is found ulcerated, — 
superficially at first, but soon the deeper parts, even the bones, 
are involved. Symptoms of blood-poison now develop, and 
closely resemble pyaemia ; the condition assumes a typhoid state, 
with rapid decline of strength, coma, and, usually, early death. 

Diagnosis. — The diagnosis is often difficult, sometimes 
impossible. The disease is rare, and unless some history of 
exposure be suggested it is usually impossible to recognize it 
in an early stage. It resembles the local manifestations of 
syphilis, scrofula, severe tuberculosis, pyaemia, articular rheu- 
matism, and typhoid fever. From syphilis and scrofula it can 
be differentiated by the chilliness and severe fever at the out- 
set ; from tuberculosis, by the absence of the premonitory 
stage if from direct infection, and from the absence of other 
evidences of tuberculosis if slow in its onset ; from pyaemia, 
by the greater shivering in the latter ; from articular rheuma- 



NASAL CROUP — CROUPOUS OR PSEUDOMEMBRANOUS RHINITIS. 65 

tism, by the absence of pain and tenderness in the joint proper 
and their presence in the neighboring- muscles and tendons ; 
from typhoid fever, by the absence of the abdominal eruption 
and tenderness and the peculiar rise and fall of the mercury. 

Prognosis. — The prognosis of acute glanders is very grave. 
The chances of a cure are greater when the nose is but slightly 
affected. Of those who apparently recover, some die at a later 
date, as the result of exhaustion. In the chronic variety about 
60 per cent seem to recover after months of suffering, but of this 
number some die from marasmus at the expiration of years. 

Treatment. — The treatment of acute farcy must be prompt. 
While local cleansing is not to be neglected, remedies are of 
chief importance. Caustics, although recommended by some, 
seem too severe. Disinfection is of the greatest importance ; a 
neglect of this may occasion a most virulent attack. The pustules 
and ulcers should be frequently washed with 10- to 20-per-cent 
carbolic-acid solution, red permanganate-of-potassium solution, 
or 15-volume peroxide of hydrogen. The remedies best indicated 
are : ars., ars. iod., chin, ars., iodine, kali bi., lach., mere, s., rhus 
tox., and sulphur. Recently three cases have been reported as 
cured by inunctions of mercury and massive doses of iodide of 
potassium internally. 

NASAL CROUP CROUPOUS OR PSEUDOMEMBRANOUS RHINITIS. 

Judging by the very infrequent reports of croupous rhinitis, 
it might be concluded that it is a very rare affection, but doubt- 
less many cases are overlooked owing to the slight constitutional 
and local symptoms which often accompany it. According to 
Potter {Jour. Lar. and Rhinol., March, 1889), it occurs in 
about 2 per cent of all cases of acute rhinitis, but I have seen 
only two undoubted non-traumatic cases. 

Etiology. — Its causes are similar to those of the same disease 
when attacking the tonsils, pharynx, larynx, etc. Just what that 
etiological factor is it is still difficult to determine; but, in the light 
of present developments, it seems imperative to class it with the 



66 DISEASES OF THE NOSE AND THROAT. 

microbic diseases, even though the special form of micro-organ- 
ism has not been discovered. Such a membranous deposit some- 
times follows intra-nasal operations, powerful local irritants, 
perchloride of mercury, etc. 

Pathology. — Pathologically, it does not differ from other 
forms of croup, and consists of a fibrinous, dead-white, opaque 
deposit upon or within the mucous membrane, sometimes easily 
detached in large pieces; at others removed with difficulty, when 
it leaves a denuded, bleeding surface. Plastic adhesions between 
the septum and turbinateds sometimes follow. It seems to be 
non-contagious, but there are reported evidences of its infectious 
nature. 

Symptoms. — Symptomatically, the disease is similar in per- 
sons of all ages, but is more frequent in childhood, when the 
malady may be ushered in with chilliness or a well-marked 
rigor ; but more frequently no complaint is made. According 
to personal experience, which agrees with most observers, there 
are few premonitory symptoms of note. There is rarely rise of 
temperature, although it sometimes amounts to 101° to 102° F. 
Symptoms of an on-coming acute rhinitis soon develop ; but, 
unlike that affection, croupous rhinitis rarely has a stage of pre- 
secretion, and the mucous process at once shows itself in the 
discharge of muco-fibrinous material, which soon becomes pro- 
fuse and purulent, though non-offensive. In some cases ob- 
struction to nasal respiration, loss of smell, and, occasionally, 
neuralgia and headache are among the early symptoms. Ex- 
amination usually reveals a pseudomembranous lining of the 
nasal cavity, covering either large areas or only small portions. 
The membrane may be well within the nasal passages and 
almost out of sight, or it may reach to the cutaneous junction. 
If there be but a slight amount of false membrane and a con- 
siderable swelling of the mucous lining, the diagnosis will be 
rendered very difficult. Cocaine should be applied if there be 
much engorgement of the tissues, in order to gain a better view. 
If the suspected region be wiped with a covered probe, portions 



PRIMARY DIPHTHERIA OF THE NOSE NASAL DIPHTHERIA. 67 

of pseudomembrane may be dislodged. This membrane does 
not extend to the pharynx, except at its vault, and it is doubt- 
ful if the accessory cavities are ever invaded by it. Nasal 
stenosis is nearly always complete. As a rule, the patient is 
not confined to his room, and may even go out-of-doors. 

In adults the symptoms and conditions are similar, but less 
in degree ; and, as it is generally easy to examine the interior 
of the nasal passages, the diagnosis is often much easier than in 
children. A counter-difficulty arises, however, from the fact 
that the pseudomembrane is usually thinner than in children. 

Prognosis. — The prognosis is favorable, but there is a 
possibility that infants may die of inanition, owing to lack of 
nursing ability, the result of nasal obstruction. The duration 
of the disease is from five days to two or three weeks. 

Treatment. — The treatment is chiefly medicinal, although, 
when there is difficult nasal respiration, it is well to dissolve or 
dislodge the membrane, if either can be done without harm to 
the underlying tissues. Lactic acid (40 per cent), menthol (10 
per cent), or peroxide of hydrogen (15 vol.), used as a spray or 
applied with a camel's-hair brush or cotton-covered probe, seems 
to be the most suitable application. Trypsin and papoid are 
used by some for the same purpose. The membrane may be 
loosened at the edges with a probe, and then extracted with the 
aid of a pair of angular forceps. A nasal tube may likewise be 
introduced, primarily to relieve respiration, and secondarily to 
induce pressure-thinning of the membrane. 

The most suitable internal remedies are : iodine, kali bi., 
kali per., and mere, dulcis (see " Croup "). 

PRIMARY DIPHTHERIA OF THE NOSE NASAL DIPHTHERIA. 

Etiology. — Nasal diphtheria is uncommon as a primary 
disease, but the nose is frequently involved secondarily, the re- 
sult of the pharyngeal affection. It is most frequent in earliest 
childhood, and this naturally leads to the thought that the dis- 
ease may be transmitted from some condition occurring in utero. 



68 DISEASES OF THE NOSE AND THROAT. 

It is very similar to acute purulent rhinitis in children, and can 
often be distinguished from it by the after-effects only, especially 
diphtheritic paralysis of the soft palate ; but there is no puru- 
lent discharge early in the course of diphtheria, while this is 
often the first symptom in the purulent affection. 

Symptoms. — This serious malady occasionally first shows 
itself in the form of a very profuse watery nasal discharge ; in 
from one to three days this may become acrid and blood-streaked. 
Pus is rarely present ; the flow consists of mucus and serum, 
and, perhaps, blood. In a variable time, — from a few days to a 
couple of weeks, — membrane may appear in the nose and phar- 
ynx, after which the course is usually rapid, and often fatal. 
The neighboring glands are frequently but little enlarged. 

Prognosis. — The prognosis is grave. Most children in 
their first weeks speedily succumb ; in older children and in 
adults, primary nasal diphtheria is not so fatal. 

Treatment. — The local treatment is similar to that recom- 
mended for croupous rhinitis ; the internal measures differ but 
little from those employed in secondary diphtheria (see "Diph- 
theria of the Air-Passages "). 

Therapeutics. 

Ammon. carb. — The membrane extends from the nose to 
the lips, the pharynx remaining free. 

Ammon. caust. — Nasal diphtheria with a burning, excoriat- 
ing discharge, and great prostration. 

Nit. ac. — False membrane, dark or yellowish-white, and 
very offensive; nasal discharge very offensive, watery, and 
excoriates the nostrils and lip. 

PARASITIC AFFECTIONS OF THE NOSE. 

Etiology. — The etiology of such affections must be based 
upon the entrance from without of the various microbes, larvae, 
and parasites essential to the production of the several varieties 
of these maladies. 



PARASITIC AFFECTIONS OF THE NOSE. 69 

Thrush is the most usual parasitic affection ; it rarely 
attacks the nose, however, except as an extension from the 
mouth or pharynx. It creates some irritation, sneezing, dis- 
charge, pain, and nasal obstruction. It is rare in adults. 
Locally, it is difficult to distinguish from croupous rhinitis, from 
which it can often be differentiated by the microscope alone. 

Other forms of nasal fungi are rare, some of which 
give rise to symptoms similar to those already noted. Their 
most frequent manifestation is very offensive nasal exhalation. 
As yet, comparatively little is known of them. 

Various insects and larvae are sometimes found in the nose, 
especially in tropical climates. Where they find entrance in 
their matured state, they are to be looked upon as foreign 
bodies rather than as parasites, and should be treated as such. 
Flies, etc., may enter during sleep or intoxication and deposit 
their eggs, which soon give rise to maggots ; if this occur in 
temperate climates, the flies are usually attracted by the pres- 
ence either of an ozsena or a long-continued suppuration or 
ulceration. 

The chief macroscopic parasites, exclusive of flies, are: 
ascaris lumbricoides, earwigs, centipeds, thread-worms, snap- 
ping bugs, oxyuris vermicularis, leeches, and cimices. 

Symptoms. — The symptoms excited depend upon the 
number, size, and activity of the intruders. Irritation, fullness, 
usually partial or complete obstruction, sneezing, headache, and 
epistaxis are among the milder complaints ; the more severe 
symptoms are fever, prostration, loss of appetite, involvement 
of the accessory cavities, pus formation in the cellular tissue, 
ulceration, caries, cerebral irritation, meningitis, convulsions, 
and coma, which may result in death. The irritation and pain 
arising from the presence of these intruders are sometimes so 
severe as to force the sufferer to commit suicide, as frequently 
occurred in Mexico during the French wars. 

Prognosis. — The microscopic parasites are curable, but 
deatli is not unusual from neglect, in the macroscopic forms. 



70 DISEASES OF THE NOSE AND THROAT. 

Treatment. — In the treatment of thrush and the micro- 
scopic parasites in general, the first object is to relieve the 
irritation, if great, by the use of injections which will serve to 
expel or kill the parasites ; if the disturbance be slight, internal 
remedies will generally so change the patient's condition as to 
result in a cure of the parasitic affection. For thrush and its 
allies, borax is the greatest remedy ; it may be used internally 
in dilution or trituration, and locally as a 10-per-cent watery 
spray. It is often possible to remove the larger parasites or 
intruders with forceps, but it is frequently necessary to first 
use a post-nasal syringe, in order to loosen them from their 
beds ; it often seems impossible, however, to extricate them 
until they have been stupefied by inhalations, either of chloro- 
form, ether, turpentine, or tobacco-smoke. When the parasites 
enter the accessory sinuses, it may be necessary to trephine these 
cavities. 

For the complications which arise, the case should be 
treated on the principles noted under the appropriate headings. 
In order to relieve the nervousness and anxiety of the patient, 
it is usually advisable to give a few doses of ignatia or hyos. ; 
and to allay the irritation, pain, and fever, aconite, calendula, 
fer. phos., or hypericum proves useful. For thrush, compare 
ars.. ba.pt., borax, mere, s., staphis., sulph., and sulph. ac. 



CHAPTER V. 

Ulcerative Diseases of the Nasal Passages. 



SYPHILIS OF THE NOSE. 

Etiology. — The syphilitic virus may attack the nose in the 
primary, secondary, tertiary, or congenital form. Primary 
syphilis is rare, and is usually carried by some object thrust into 
the nose, especially the finger ; the secondary form is most fre- 
quent, and is the result of the natural tendency of the disease, in 
this stage, to attack the mucous surfaces ; the tertiary form is also 
very frequent ; hereditary nasal syphilis is comparatively rare. 

Pathology. — In the primary lesion, the same pathology is 
in force as when occurring upon the genitalia; when the second- 
ary form occurs directly after the invasion, there is only a slight 
erythema, usually not distinguishable from an ordinary nasal 
inflammation and often diagnosed only by the history and the 
concomitant symptoms and appearances. Some observers think 
this a part of the primary stage, so closely does it occasionally 
follow it. When the secondary lesions appear some time after 
the primary infection, mucous patches, papules, abrasions, and 
superficial ulcerations may occur ; gummata are rare. In the 
tertiary stage, which may occur as early as the seventh month 
after infection, mucous patches, gummata, deep ulcerations, and 
caries and necrosis of the cartilages and bones are among the 
frequent manifestations. The ulcer is deep, excavated, with 
ragged, overhanging edges, and with the surrounding mucous 
membrane much reddened. Polypi and exuberant granulations 
occasionally develop around the edges of the excavation. The 
hereditary form is similar in most respects to the tertiary. 

John N. Mackenzie {Jour. Lar. and Rhin., April, 1889) 
describes a fibroid degeneration of the nasal passages, especially 
of the turbinateds. 

(71) 



72 DISEASES OF THE NOSE AND THROAT. 

Sijmptoms. — The symptoms vary with the condition present. 
With the primary lesion there is some soreness, decided ten- 
dency to bleed, a circumscribed fungous mass, and enlargement 
and tenderness of the submaxillary or post-cervical glands. In 
the secondary form, with the erythematous condition, there are 
usually no marked or characteristic symptoms; with the mucous 
patch, there is a sensation of fullness and stiffness; when there 
is superficial ulceration, pain is a frequent, although not a severe, 
symptom. The secretions may form in thick crusts, and emit a 
very offensive odor (syphilitic ozaena) ; slight haemorrhages are 
not unusual. 

The tertiary form is characterized by ulceration, difficult 
nasal respiration, nasal voice, pain, and haemorrhages. The 
secretions are often offensive. If necrosis and caries exist, much 
pain is experienced and haemorrhages may be quite profuse ; the 
stench is intense, requiring fumigation and airing in order to 
render the surroundings of the patient endurable. The sep- 
tum, in the early stage of the tertiary form, is often so thick- 
ened as to obstruct the nasal passages ; or the turbinateds may 
be so infiltrated as to meet the septum, even though the latter 
be not thickened. The septum is often perforated, — the trian- 
gular cartilage usually yielding first, in which case the bridge 
of the nose falls in ; if the bony septum be destroyed and the 
cartilaginous portion remain intact, the bridge of the nose does 
not always fall, and no especial disfigurement results. Fre- 
quently, the floor of the nose (roof of the mouth) is perforated, 
— usually by ulceration beginning within the nose, but occa- 
sionally on the roof of the mouth over the hard palate, or at the 
juncture of the hard and soft palates. This is often followed by 
passage of food into the nose during deglutition. The bone-de- 
generation may extend to the frontal or sphenoidal region, and, 
as the result of the inflammatory or suppurative process, the 
skull may be perforated, giving rise to fatal meningitis. A large 
portion of the soft parts of the nose, posterior nasal region, and 
soft palate may also become involved in the destructive process. 



SYPHILIS OF THE NOSE. 73 

Hereditary syphilis often appears in utero or directly after 
birth. In the latter instance, its first manifestations are nasal 
catarrh, or snuffles, and a cutaneous eruption. The nose is 
usually obstructed ; but with a watery discharge, which later 
becomes muco-purulent and acrid. The diagnosis must often 
depend upon the history and the concomitant symptoms. Later 
in the disease, gummata appear. These soon break down, 
giving rise to well-marked ulceration, with the characteristic, 
purulent, offensive, bloody discharge, which often contains shreds 
of necrotic tissue. The discharges dry in hard crusts about the 
nostril, often completely blocking the opening. Its course is 
exceedingly rapid, necrosis of bone and external deformity often 
occurring within a few weeks, the disease usually manifesting 
itself from one to three months after birth. 

The symptoms of the late hereditary form are not unlike 
those of the tertiary affection, though usually more sluggish in 
their action and less severe in their results. The septum and 
floor of the nose may be perforated and the soft tissues, including 
the uvula and soft palate, more or less destroyed. With all the 
forms of syphilitic rhinitis the hearing may be impaired, but 
this is especially true of the tertiary and hereditary manifesta- 
tions. The pharynx and larynx very generally share in the 
severer forms of the disease. 

Prognosis. — The prognosis depends upon the extent of the 
affection at the time treatment is commenced, the virulence of 
the condition, the stage of the disease, and the general state of 
the patient. If it be possible to modify the intensity of the poison 
by treatment, diet, hygiene, exercise, etc., the condition is to be 
looked upon favorably ; otherwise, not. Even in apparently 
hopeful cases most unhappy results may follow, as it is not 
always possible to regulate or modify the virulence of the 
poison, and perforations will sometimes occur in spite of the 
most approved treatment. The hearing is often restored by 
relieving the nose and naso-pharynx. If the cicatrices remain 
permanently, the voice will be nasal and respiration be ob- 



74 



DISEASES OF THE NOSE AND THROAT. 



stmcted. The cicatricial contractions and bands may, however, 
sometimes be reduced, as suggested under " Stenosis of the 
Pharynx." Food may regurgitate through the defective pos- 
terior nares or perforation in the hard palate. The external 
deformity is rarely overcome. 

The prognosis of the early hereditary form is usually bad, 
if the disease occur directly after birth ; the longer it is delayed, 
the less serious is the prognosis, as the child is better able to 
withstand the poison and to nurse. 

Treatment. — The treatment should be chiefly constitutional. 
Local measures, further than cleanliness and disinfection, avail 

but little. For decided ulceration, 
cleanliness is of inestimable advan- 
tage, and, where there is an intense 
ozaenous odor, disinfection and de- 
odorization are necessities (see 
" Ozsena"). Cauterants are inadvis- 
able, as they often tend to aggra- 
vate the symptoms. If there be 
loose, necrosed or caried, bone, it 
should be removed with forceps or 
curette. If the sequestrum be loose, 
but too large to remove through the 
ulcerated sinus, the latter should be 
first enlarged with a small, blunt- 
pointed bistoury. The after-care consists in frequent antiseptic 
spraying, when the opening will soon close. If the bone be only 
denuded, it had better be curetted. In infants with congeni- 
tal syphilis, it is frequently necessary to spray the nostrils, and 
then wipe them out carefully with pledgets of absorbent cotton 
or blotting-paper, or to introduce small rubber tubes through 
the inferior meatus, in order that they may have space for respira- 
tion during nursing. As their only mode of clearing the nostrils 
is by sneezing, this may be produced reflexly, by tickling the nose. 
Syringing is scarcely advisable, as it may force the fluid into the 




THERAPEUTICS OF SYPHILIS OF THE NOSE. 75 

deeper air-passages and cause spasm of the larynx. Politzer's 
air-bag is to be given the preference, as, with it, the air-current 
forces the discharges into the naso-pharynx, at the same time 
that it frees the nasal passages and inflates the middle ears. 

In the early stages of the acquired form, mere. iod. is very 
effectual ; but if there be oedema or infiltration, two to five 
grains of kali iod. crystals (in solution) should be given three 
times daily. In the tertiary form kali iod. is most applicable, 
but the treatment is not to be confined to the remedies 
noted, as special indications may call for others. In the con- 
genital variety, when the disease shows itself soon after birth, 
mere, dulcis is often the most appropriate remedy. 

Therapeutics. 

Asafcetida. — Offensive, greenish discharge, with caries of 
the bones, and a feeling as if the nose would burst. 

Aurum met. — Caries of bones of nose and palate ; sinking 
of the bridge of the nose ; horribly offensive odor ; burning, 
itching, smarting; sensitiveness of the nose; yellow, thick, 
offensive discharge. 

Aurum mur. — Ulceration of mucous membrane and carti- 
lage ; caries of nasal bones ; perforation of bony and cartilagi- 
nous septum. Horribly offensive odor; greenish-yellow or 
yellow discharge ; offensive crusts and scabs are blown from the 
nose or hawked out. Nose sensitive to pressure ; mental de- 
pression, suicidal intent. 

Hecla lava. — Ulceration, with caries of the nasal bones. 

Kali bi. — "Carious nasal bones. Syphilis of the nose; 
yellow discharge ; nasal ulceration ; pain across the bridge of 
the nose. Ejection of plugs of yellow, sticky, stringy mucus " 
(Morse, " Nasal Catarrh "). Perforating ulcer of the septum ; 
ulceration of lining membrane. 

Kali iod. — One of the best remedies for nasal catarrh oc- 
curring in syphilitic patients. Ozsenous odor ; greenish-yellow, 
excoriating discharge. Nose red and swelled; throbbing, burn- 



76 DISEASES OF THE NOSE AND THROAT. 

ing in the nasal and frontal bones ; deep ulcers. I have repeat- 
edly seen intense septal deposits (perichondritis, gumma'?) dis- 
appear in a few days, without leaving an appreciable change. 
Drop doses of the saturated solution were given, three times 
daily, in a teaspoon ful of water. 

Merc. cor. — Perforating ulcer of septum and other deep 
ulceration ; burning pains and acrid discharge. 

Nit. ac. — Destructive process of cartilages and bones ; mer- 
curial aggravation of the syphilitic poison. Copious, acrid, 
bloody discharge, anteriorly and posteriorly ; lining membrane 
is granular in appearance, or ulcerated. The Eustachian tubes 
are involved, and the hearing usually impaired. 

Sang. can. — " Tertiary form affecting the nasal lining ; 
various-sized patches secreting a diphtheritic-like exudation, 
which, when wiped off, leaves a wounded surface. . . . The 
nasal discharge stops for a few days, and then returns, making 
an alternate dry and fluent coryza." (Charge.) 

(See "Syphilis of the Pharynx" and "Syphilis of the 
Larynx.") 

LUPUS OF THE NOSE EROSIVE ULCER. 

Although the primary manifestation of lupus within the 
nasal canals is not especially rare, it usually appears first on the 
skin surface of the nose or in the pharynx, whence it extends 
to the deeper parts of the nose. If it originate within the nose, 
it makes its appearance first on the septum. It is chiefly found 
in young and scrofulous persons. 

Pathology. — It may appear either as lupus exegens or 
lupus non-exegens. In the former variety there are nodes 
(granulation tissue) which are followed by ulceration, both 
superficial and deep. These ulcers have a tendency to heal 
at one point, leaving a red, glistening scar; while at another 
the ulceration continues, or even increases in extent. Necrosis 
and caries of the cartilages or bones may occur. In lupus non- 
exegens ulceration does not appear, but the tissues, including 
the bones and cartilages, may shrivel. 



LUPUS AND SCROFULA. 77 

Symptoms, — Subjectively, the symptoms are not character- 
istic, but the condition can usually be diagnosed objectively. 
The discharges accumulate on the surface of the ulcers, forming 
crusts, which, if removed, frequently occasion bleeding, followed 
by a thin, sero-mucous discharge. Finally, the pharynx and 
larynx usually suffer. 

Diagnosis. — The diagnosis is not difficult, if there exist 
other evidences of lupus ; otherwise, it may be confused with 
syphilis, with which it is often associated, or with tuberculosis 
or scrofulosis. Inspection often reveals the presence of a red- 
dish or brownish, granular, exceedingly soft, and insensitive 
mass, covered with tenacious mucus. 

Prognosis. — The prognosis is to be guarded, for, although 
many recover (some spontaneously), there remains the possi- 
bility that the disease may recur, though not necessarily in the 
same region. 

Treatment. — The treatment is not always well defined. It 
is usually taught that the ulcer should be scraped or cauterized, 
for the purpose of limiting it ; in that case, every particle of 
the diseased structure should be removed or destroyed by caus- 
tics or the cautery, but the efficacy of the procedure, as applied 
to the nose, is a doubtful one. While in some instances it 
appears to control the extension of the disease, in others it 
seems to have no influence, or the ulceration may even spread 
more rapidly. Locally, the best results follow the application 
of an 80-per-cent lactic-acid solution. 

Alumen., ars., aurum mur., caust., hydrast., iodine, kalibi., 
kreos., sulph., and thuja are the most efficient remedies. 

SCROFULA. 

No attempt will be made to settle the vexed question of 
the relationship of tuberculosis, lupus, syphilis, and scrofula. 
While some authorities consider every chronic rhinitis with 
swelled anterior cervical glands a scrofulous rhinitis, others think 
it necessary that there be actual ulceration, or even caries and 



78 DISEASES OF THE NOSE AND THROAT. 

necrosis ; but. as the mid-position seems the most probable, the 
condition will be considered from that stand-point. 

Pathology. — Its pathological changes consist in sluggish 
lymphatic and circulatory function. The glandular elements 
retain much of the detritus that should be eliminated by them ; 
in this manner the nasal mucous membrane, glands, and muscles 
frequently undergo sluggish ulceration, and even the bones and 
cartilages suffer. 

Symptoms. — Symptomatically, the condition which first 
calls attention to the nose is the presence of a profuse, offensive, 
perhaps ozaenous, discharge. The nasal passages may be either 
considerably obstructed or quite free. There is rarely pain, 
unless the deeper tissues or accessory sinuses be diseased. The 
discharge often parts with its moisture so rapidly that it dries 
on the surface of the membrane, and gives rise to the condition 
referred to under " Atrophic Rhinitis." Inspection reveals 
offensive, dry crusts on a pale or dusky-red pituitary membrane. 
The turbinateds may be early enlarged, but, as a rule, they are 
wasted, and the septum is quite thin and, perhaps, perforated in 
several places ; in this it differs from syphilis, in which there is 
usually one large perforation, resulting in deformity. There 
are nearly always other evidences of scrofula ; for example, 
eruptions, enlargement of the cervical and other glands, or 
scars indicative of former lymphadenitis. The pharynx, ears, 
and larynx may participate, and the soft palate be perforated 
or partially destroyed. 

Prognosis. — The prognosis is not generally unfavorable, 
but perforations of the septum may result in deformity and 
great annoyance ; ulceration of the soft palate may be followed 
by regurgitation of food into the nose ; cicatricial adhesions may 
hinder or prevent nasal respiration and induce nasal tones. 
The hearing may be permanently impaired, or even lost. If 
care have been exercised and treatment carefully and persistently 
pursued, the milder local forms of the disease usually disappear 
as puberty approaches. 



TUBERCULOSIS. 79 

Treatment. — The treatment is chiefly constitutional. If 
there be an ozaenous odor cleanliness and disinfection are to be 
used, and if diseased bone be found the treatment outlined 
under "Syphilis of the Nose" should be instituted. Ulcera- 
tions are to be relieved by the use of both internal and local 
remedies ; of the latter, boric acid and calendula are valuable. 
Diet, hygiene, fresh air, exercise, and codliver-oil and terraline 

are important. 

Therapeutics. 

Alumina. — Scrofulous ozsena and ulceration of the mucous 
membrane. 

Aurum mur. — Scrofulous ozsena, with unbearable odor ; 
ulceration of nasal cavities, even perforation of septum ; nos- 
trils rilled with hard, offensive crusts. 

Carbo. an. — Scrofulous ozsena; pimples or little boils inside 
and outside of the nose. 

Hydrast. — Ulceration of the mucous membrane; bloody, 
purulent discharge ; cartilaginous septum sore, — bleeds when 
touched ; post-nasal catarrh. 

In addition to the foregoing, calc. carb., calc. fluor., hepar, 
iodide of lime, iodine, kali bi., kali iod., silica, and sulph. are 
often indicated. (See "Ozaena" and "Syphilis of the Nose.") 

TUBERCULOSIS. 

Although this is one of the rarest manifestations of tuber- 
culosis, its existence cannot be ignored. It may attack the nose 
primarily, but is generally secondary. It may show itself as 
small tubercles or tumors, granulation proliferations (lupoid 1 ?), or 
as superficial or deep ulcerations, with involvement of the bones 
and cartilages. 

Etiology. — The etiology of nasal tuberculosis is the same as 
that of tuberculosis in general, but is apparently furthered by 
marked nasal catarrh and erosions. 

Pathology. — The pathological changes consist chiefly in 
the development of miliary or giant-celled tubercles, tumors, 



80 DISEASES OF THE NOSE AND THROAT. 

raspberry-shaped excrescences, or small, gray ulcers, which may 
remain in their primary condition for years. Although the 
ulcers are generally superficial, and situated on the septum 
(about one-half inch from the nostril) or turbinateds, they may 
become deep, and cause perforation of the septum, with a loss 
of part of the turbinateds. The ulcer is usually oblong, with 
slightly raised, but not wall-like, elevated granulation edges, as in 
lupus. (Hahn, Bent. Med. Woe-hens., June 5, 1890.) The surface 
of the membrane is grayish pink, upon which small, yellow 
spots (tubercles'?) are often seen, and which, later, may undergo 
ulceration. The surface of the ulcer is usually whitish gray and 
on a level with the surrounding mucous membrane. Its out- 
lines are somewhat irregular and unattended by an areola. 

Symptoms. — The symptoms are often unimportant. In 
the mild forms they may not attract attention for some time ; 
on the other hand, there may be intense pain and a profuse, 
offensive discharge. When ulceration is present crust-forma- 
tions are not rare and slight haemorrhages are frequent. The 
disease may involve the pharynx, extend to the larynx, or 
destroy the hearing. 

Diagnosis. — The diagnosis is difficult, often impossible, 
except by exclusion. It must be separated from lupus by the 
absence of the granular appearance and cicatrices ; from syphilis 
(if the two do not co-exist) by the history, the concomitant 
symptoms, and the microscope. 

Prognosis. — The prognosis is usually grave, although the 
progress is slow, the period of ulceration sometimes lasting 
many years. When removed, the tumors may not re-appear 
for years, sometimes never ; but in the ulcerative form, associ- 
ated with pulmonary changes, the prognosis is dependent upon 
the general condition. 

Treatment. — Cleanliness, disinfection, and deodorization in 
general should be coupled with the application of lactic acid 
(40 per cent), eucalyptol (10 per cent), menthol (5 per cent), 
and the very important constitutional, hygienic, dietetic, and 



TUBERCULOSIS. 81 

climatic treatment. Many advise that the tumors be removed 
and the ulcers scraped and disinfected. The internal remedies 
indicated and the further local measures will be found under 
" Tuberculosis of the Pharynx " and " Tuberculosis of the 
Larynx." 



CHAPTER VI. 

Pollen Catarrh — Hay Fever — Summer Catarrh — 
Periodical Vasomotor Rhinitis. 

Pollen catarrh was formerly supposed to be an affection 
of the wealthy classes alone ; such is not, however, strictly true, 
but it is more frequent in those of sedentary habits. Heredity 
seems to have some influence; age and sex play a part, in that 
it rarely occurs before the tenth year and seldom first appears 
after the twenty-fifth. It is about twice as frequent in males as 
in females. The malady was originally called catarrhus sestivus ; 
later, hay fever, etc. Pollen catarrh, rose cold, summer catarrh, 
and autumnal catarrh are the names which should, in the future, 
distinguish this affection. 

Pathology. — Two pathological theories of especial note 
have been advanced ; one relegates hay fever to the class of 
pure neuroses, with the periodical exacerbations characteristic 
of nervous manifestations ; the other places it among the 
reflexes due to intra-nasal disease. 

Etiology. — Pollen of grasses, flowers, etc., seems to be the 
direct exciting cause ; but, " Since comparatively few persons 
are victims of the affection, there must be some peculiarity, 
either inherent or acquired, which acts as the predisposing ele- 
ment in precipitating the attack. That this proclivity or idio- 
syncrasy resides in the nose there is but little doubt ; where else 
in the economy it has its counterpart, I do not pretend to say ; 
but this much is certain, that such a condition on the part of 
the nasal passages is an essential of periodical vasomotor rhi- 
nitis. Two factors, then (pollen irritation and idiosyncrasy), 
are essential to the presence of the paroxysm, either of which 
being absent, the other must prove inoperative. 

" Most recent writers lay much stress upon the presence of 
a neurotic feature in every case, and, although not thoroughly 
(82) 



POLLEN CATARRH. 83 

convinced, I am free to admit that in most patients a nervous 
element is present ; yet it is quite true that in others it is appa- 
rently absent." (See paper by the author, Trans. Amer. Ins. 
Horn., 1891 ; Jour. Opli., Otol, and Lar., July, 1891.) 

Pollen catarrh usually makes its appearance, in America, at 
any time from the first of May to the last of September. The 
so-called rose cold appears in the Middle States about the first of 
June; further south it appears earlier than this, and further north 
still later. Rose cold rarely assumes the asthmatic form. When 
the affection begins in the middle of summer, from the beginning* 
of hay harvest, it is usually called hay fever ; the condition rarely 
lasts through both seasons. A third variety appears only in the 
autumn, and is then appropriately called autumnal catarrh. 
The term pollen catarrh applies to the condition in its entirety. 

There are few portions of the civilized world in which the 
disease does not manifest itself, but it is less prevalent where 
the verdure is scanty, while in some localities it never occurs ; 
these resorts are a great source of comfort to hundreds of the 
victims of this tormenting affection, which, according to the late 
Rev. Henry Ward Beecher, is " worse than the Inquisition." 
With the exception of tinnitus aurium, it is doubtful if there 
be any non-febrile disease so distressing ; there is sometimes no 
possibility of evading it, sleeping or waking, day or night, in 
the house or out-of-doors. Fortunately, however, recent methods 
of treatment have succeeded in doing much to alleviate the 
condition, and many are now enabled to live in comfort who, a 
few years ago, if remaining at home, were doomed to weeks of 
the trying ordeal. 

Although there is possibly no place in this country where 
every hay-fever patient may find immunity from his paroxysms, 
there are many so-called hay-fever resorts where most of its 
victims may find a harbor during its prevalence. Those of chief 
importance are: portions of the coast of New Jersey; the White 
Mountains; the Catskills; Allegheny, Adirondack, Rocky, and 
Sierre Nevada Mountains ; Lakes Chautauqua and Superior ; 
Put-in-Bay; Colorado Springs; and Hot Springs of Arkansas. 



84 DISEASES OF THE NOSE AND THROAT. 

Bright sunlight is responsible for aggravating the attack, 
but it cannot produce it ; and the sufferers exposed to that element 
are often greatly annoyed at such times, — doubtless owing to the 
greater prevalence of pollen grains, which Blackley has demon- 
strated are the exciting cause. It is well known that the pres- 
ence of flowers in the house is often sufficient to cause an attack, 
independent of direct exposure to sunlight or season ; and many 
persons subject to the disease can remain, without discomfort, in 
the bright sun the whole day if not in the locality of vegetation, 
as, for example, on barren islands or on the ocean ; but the 
inhalation of the pollen of verdure, added to the preceding, 
may at once excite an attack of pollen catarrh. On the ocean 
this affection is almost unknown, and where it has appeared the 
onset could usually be traced to some accidental occurrence, 
such as the presence of dust from some portion of the trunks or 
cargo which has, perhaps, contained some of the pollen of the 
obnoxious flora ; or, as Blackley has shown, these grains can 
be carried a long distance on ocean breezes. Dead, dried flowers 
are often more pernicious than when growing or freshly cut. 
Vasomotor dilatation and psychical influence play some part in 
the paroxysm. 

Symptoms. — The symptoms of the affection vary with the 
individual and even with the attack. Those which are charac- 
teristic of hay fever are a premonitory sense of drowsiness, lassi- 
tude, and weariness. The attack declares itself by sneezing, 
often in long paroxysms, and itching or burning of the nose, eyes, 
and roof of the mouth. Soon the eyes begin to water, and the 
nose to exude a thin, ichorous discharge. The eyes often burn 
and become quite congested, the entire conjunctival surface 
seeming to exude a profuse lachrymal flow. In some cases 
respiratory efforts by the nose are very fatiguing, difficult, or 
impossible, owing to the swelled and turgid nasal mucous mem- 
brane. As a result, the mouth is opened ; headache makes its 
appearance ; the pharyngeal lining becomes dry and irritated, 
the larynx irritable and catarrhal ; cough makes its advent, and 



POLLEN CATARRH. 85 

in some cases the bronchial complications are such as to favor 
the diagnosis of bronchial catarrh with asthma. Year by year 
the asthma becomes a more pronounced feature of the attack, 
until finally the characteristic pollen-catarrh seizures may give 
place to asthma, the latter constituting the attack. 

It is not to be understood that one patient suffers from all 
of these symptoms at the same time, for such is rarely the case, 
but the head and throat symptoms are often associated, and the 
same is true of the head and chest ; on the other hand, the 
symptoms enumerated are not the only ones that harass the 
poor victim of this yearly scourge, but the foregoing present a 
sufficiently accurate picture to prevent any error. 

Diagnosis. — The diagnosis, it will be seen, is not a difficult 
matter in these cases, as acute nasal catarrh is the only con- 
dition with which pollen catarrh could be easily confounded. 
From this it may be distinguished by the appearance of the 
latter affection, as the result of exposure to a draught of air, or 
some other cause giving rise to an acute coryza. Again, hay 
fever is not soon followed by a profuse, thick discharge, as is the 
case with acute cold in the head. Further, catarrh is usually a 
condition of inclement, changeable weather, while pollen catarrh 
is strictly a summer visitation. In acute rhinitis the membrane 
is greatly congested and coated with a partially-opaque dis- 
charge at an early date ; whereas, in pollen catarrh the mem- 
brane is pale or grayish and the coating serous. In this latter 
affection the venous sinuses are affected almost exclusively ; in 
acute rhinitis the capillaries of the mucosa are engorged. At 
the outset the two conditions are very similar, but in a few days 
the diagnosis is easily determined. Those who have chronic 
nasal catarrh, either of the simple or the hypertrophic form, are 
subject to hay fever and to acute exacerbations of their condi- 
tion ; but these affections can be differentiated by the duration, 
the season, and by the previous personal experience. Polypi 
of the nose may simulate this affection, but the history and 
examination will serve to differentiate ; traumatism and syphilis 
are easily excluded. 



86 DISEASES OF THE NOSE AND THROAT. 

Prognosis. — The prognosis is generally favorable. Although 
the paroxysms may recur punctually year after year, perhaps on 
the same date, or possibly the same hour (partially psychical), 
many cases recover, and all can be benefited. The victim 
usually suffers yearly, if exposed to the exciting influence, 
unless the constitution be so changed by remedies as to remove 
the susceptibility to the attack, or local measures destroy the 
direct nasal disorder. There is some peculiarity which enables 
one victim to live in comfort where his fellow-sufferers cannot. 
A rain-fall often so purifies the atmosphere as to greatly alle- 
viate the attack ; but usually this continues until it has " worn 
itself out," or the special excitant has disappeared with the 
rotation of flora. There are seasons, usually quite damp, dur- 
ing which hay fever is comparatively mild ; finally, a person 
may outlive a part of his tendency to this malady. 

Treatment. — It is now pretty certain that the predisposing 
irritation is in the nose ; on that account, special remedial efforts 
should be directed to this organ, to combat congestion, hyper- 
trophy, septal deviations and tumors, including ecchondroses 
and exostoses. In the majority of instances, the proper method 
to pursue is to treat these defects, during the intervals of the 
attacks, by the use of internal or local measures, thereby sub- 
duing the tendency to the affection. Some advise the use of 
destructive agents for the purpose of eliminating certain " sen- 
sitive areas," thus doing away with that possible source of irri- 
tation ; for this purpose, the galvano-cautery point is heated 
almost to a white heat, and drawn over the area recognized as 
" sensitive " by previous trial with a blunt-pointed probe. Care 
must be taken not to destroy more than the exact point desired, 
lest sacrifice of the surrounding healthy tissue prove harmful. 
Although destruction of these areas does something toward the 
relief of the subsequent attacks, it has not met the success that 
was anticipated. 

If the turbinated bodies be infiltrated or hypertrophied, 
they are best reduced by the use of a very fine, highly heated 



THERAPEUTICS OF POLLEN CATARRH. 87 

galvano-cautery knife-blade drawn through the most prominent 
part. Should the first treatment give insufficient relief, it will 
be safe to repeat the incision, avoiding the surrounding healthy 
tissue by following the same line. Hypertrophic tissue should 
be dealt with as directed under " Hypertrophic Rhinitis," and 
bony hypertrophy or exostosis sufficient to interfere with the 
proper respiratory channel should be treated as suggested under 
" Nasal Tumors." 

As cocaine is so transient in its effects, so apt to lose its 
happy action in allaying irritation and reducing engorgements, 
and, in strong solutions, so prone to induce constitutional dis- 
turbances, I use it very sparingly ; never stronger than a 4-per- 
cent solution, and usually but once daily, at the hour when the 
greatest aggravation is apt to occur. 

If all obstruction be removed, so that the patient has free 
nasal respiration during the interval of the attacks, there are few 
whom medicines will not render fairly comfortable, even in their 
own homes. In many cases remedies will greatly alleviate the 
suffering where mechanical means prove unavailing. It is not 
to be expected that entire relief can be given the first or even 
the second year, but the cases are few in which decided benefit 
will not follow the first year's careful prescription, especially if 
the patient be treated early. In order to allay the nasal itching 
and obstruction, a 10-per-cent solution of naphthalin, a 2-per- 
cent solution of menthol, or a -j^-per-cent solution of chromic 
acid, in fluid cosmolin or fluid albolene, should be dropped or 
sprayed into the anterior nares. 

Therapeutics. 

Ars. alb. is indicated in conditions similar to those calling 
for ars. iod., but in which there is less prostration, less glandular 
involvement, and more asthma. 

Ars. iod. — Dr. E. M. Hale looks upon this as nearest to a 
specific. Dr. Blackley ("Hay Fever," 2d edition) gives it "the 
palm " for its " prophylactic properties in the early stage of hay 



88 DISEASES OF THE NOSE AND THROAT. 

fever " ; and Dr. J. H. McClelland looks upon it as one of the 
best remedies " when asthma is a prominent symptom." This 
remedy is called for in anaemic, delicate persons ; it produces 
glandular enlargements, even to the follicles of the pharynx. 
The excoriating discharges, prostration, paleness of face, and 
burning and itching of all the affected mucous surfaces are im- 
portant characteristics. Its use is most potent in the 3 x and 4 x 
triturations, but the doses should not be too frequently repeated, 
neither should the drug be given for prolonged periods. 

Artemisia bears an undoubtedly strong relationship to this 
affection as it occurs in the later months of the season, if asso- 
ciated with asthma. 

Benzoic ac. — Highly praised by Dr. Samuel A. Jones, of 
Ann Arbor. 

Cepa. — As a prophylactic for cases which do not present de- 
cided symptoms of another remedy, a dose of the 80 x or 200 x 
once daily. This should be continued until the appearance of the 
paroxysm, if it occur, when a remedy is to be selected accord- 
ing to the most prominent symptoms. In many instances, how- 
ever, the attack is so mild or so delayed that the cepa should be 
continued until the usual pollen-catarrh period has passed. 
The chief indications for the remedy are : immoderate sneezing ; 
profuse, bland, or excoriating watery flow from the nose and 
eyes ; much itching of the nose, conjunctiva, and naso-pharynx ; 
and nasal obstruction, headache, and disturbance of sleep and 
appetite. Further indications are dropping of fluid into the 
pharynx, slight hoarseness, and laryngeal tickling and cough. 
It is of special value if dust and the odor of onions aggravate. 

Chin. ars. is a remedy of undoubted clinical value ; but, as 
yet, I cannot strictly place its symptoms. So far, however, it 
has acted better in females, where there were associated men- 
strual irregularities, loss of appetite, nervousness, despondency, 
and tendency to insomnia. It is deserving of repeated trials, 
and, judging by my limited use of it, must prove very efficient 
in pollen catarrh. 



THERAPEUTICS OF POLLEN CATARRH. 89 

Euphrasia has served to lighten the attack by controlling 
the profuse, excoriating lachrymation, swelling, and inflamma- 
tion of the lid-margins, together with burning and itching, not 
only causing the patient to wink frequently, but to rub the 
eyes. 

Gels, often relieves the premonitory symptoms, chiefly the 
fullness in the frontal region, dryness in the nasal fossae, and 
mild nasal obstruction. This remedy is rarely indicated unless 
there be pain in the occipito-cervical region. 

Naphth. is frequently preventive in its effects ; but it is in 
its curative sphere that it stands second only to cepa. In order 
to obtain good results I have been obliged to use the remedy in 
the 2 x or 3 x trituration, as it seems almost inoperative in the 
higher preparations. One of its chief indications is a high de- 
gree of asthma. With naphth. there is more fullness in the 
frontal region, more swelling of the conjunctiva (chemosis), 
more puniness of the whole face than in cepa, and the secre- 
tions are usually more excoriating. Dr. E. Lippincott says 
("Hay Fever ") : " In rose cold I have never given any other 
remedy, and have cured every case, though the number is not 
great." F. F. Laird {Trails. Horn. Med. Soc. State of N. Y., 
1888) wrote: "While it seems to benefit all cases of this 
strange neurosis (?), it is especially adapted to patients who 
experience more or less asthmatic symptoms. I may safely say 
that naphthalan is to ' hay asthma ' what aconite is to synochial 
fever, — as near a specific as anything in medicine can be." If 
the conjunctiva be much affected a 5-per-cent solution of the 
crude drug should be instilled into the lachrymal sac, as occa- 
sion requires, generally with the happiest results. If there be 
marked photophobia, the daily instillation of a J- to 1-per-cent 
solution of cocaine often assists materially, as will boric acid 
(1 per cent), glycerin (pure or diluted), or warm salt water. 

Nux vom. has repeatedly afforded marked relief to the 
nightly asthmatic attacks. ; Incessant sneezing and continual 
watery discharge. 



90 DISEASES OF THE NOSE AND THROAT. 

Rosa D. (6 x to 30 x) often acts prophylactically and cura- 
tively for the spring form of the disease ; later in the season I 
have never found it of much benefit, and it is not suitable for 
the asthmatic form of the affection. 

Sabadilla. — Abundant serous discharge, violent sneezing, 
lachrymation, frontal headache, and heat and redness of face 
and eyes (Bayes). The spasmodic sneezing and copious lachry- 
mation are worse in the open air or bright light ; eyelids in- 
flamed. This remedy acts well as an aqueous spray (1 to 10 
of the 3 x). 

Sang. can. — Susceptibility to odors which sometimes cause 
faintness. The lining membrane of the nose and throat is dry, 
irritated, raw, and burning, as if scalded or denuded of epi- 
thelium. The coryza is fluent and excoriates the nostrils, the 
right the worse. 

Sang, nit., by controlling the hypertrophic tissue in the 
naso-pharyngeal region, has prevented subsequent attacks. 
Calc. phos., as advised by Dr. Robert T. Cooper for adenoid 
vegetations, is of equal or even greater value, in some instances, 
than the last-named remedy. 



CHAPTER VII. 

Neuroses of the Nose. 

Under this heading will be found two sets of nervous dis- 
orders, — (a) those of sensation and (b) those of special sense. 
In the production of the former the trigeminus, or fifth cranial, 
nerve is affected somewhere in its course ; and in the latter the 
function of the olfactory is impaired. 

(a) ANESTHESIA, HYPERESTHESIA, NEURALGIA, AND REFLEX 

CONDITIONS. 

Anaesthesia (lack or loss of sensation of the nasal mucous 
membrane) is a result of defects in the fifth cranial nerve, either 
at its origin, somewhere in its course, or in its terminals. It 
may, however, be reflex, the result of a purely neurotic con- 
dition. The diagnosis is made by the absence of sensation or 
of reflex nasal symptoms, when the Schneiderian membrane is 
irritated. Uncomplicated anaesthesia is quite rare. 

Prognosis. — Its prognosis is usually unfavorable ; few cases 
recover unless of an hysterical origin. 

Treatment. — Medicinal treatment is chiefly to be relied 
upon; galvanism is not to be recommended, as a current strong 
enough to be of service may injure the retinas and cause much 
swelling, or even decomposition, of the nasal mucous lining. 
The chief remedies are hyos., ignatia, gels., and caust. 

Hyperesthesia (undue sensitiveness) may be local or reflex. 
In the former instance it is due either to catarrhal conditions or 
to the presence of irritating bodies, vapors, etc. ; and when re- 
flex, to intestinal, rectal, and other remote causes. 

Prognosis. — The prognosis is usually good, but a cure is 
not always possible. The duration of the disease varies from a 
few days to as many years. 

(91) 



92 DISEASES OF THE NOSE AND THROAT. 

Diagnosis. — The diagnosis is made by testing the sensi- 
tiveness to irritants, to the contact of a probe, to the effect of 
sunlight upon the eyes, etc. In diagnosing such conditions, we 
should bear in mind the fact that normal nasal reflexes vary 
within physiological limits. 

Treatment. — The first object of treatment is to remove the 
cause. In addition, the eradication of intestinal worms often 
relieves the itching and boring at the nose. The remedies are 
to be selected upon the symptoms presented, after careful diag- 
nosis of the condition. They are chiefly gels., bell., colch., 
hyos., and spigelia. 

Neuralgia is often the result of local nerve-pressure or irri- 
tation, but may be reflex from aural or dental involvement of 
the nerve. It sometimes follows the various operations upon 
the nose, especially about its floor. 

Prognosis. — The prognosis is good, the duration usually 
short. 

Treatment. — The treatment is generally gratifying, and 
may consist of local washings, cocaine applications, chloroform 
inhalations, insufflations of finely powdered salt, etc. 

Internal remedies are the most potent in the majority of 
cases. Aeon., bell., fer. phos., gels., mag. phos., and spigelia 
are to be compared. 

Reflex conditions, dependent upon "hyperasmia rather than 
hypertrophy" (Hack), include sneezing; supra-orbital and facial 
neuralgia ; headache ; eye affections, including conjunctivitis, 
phlyctenulae, blepharospasms, twitching of the lids, asthenopia, 
muscse volitantes, scotoma, glaucoma, and even blindness ; 
asthma ; chorea ; external nasal erythema ; nasal cough ; syn- 
cope ; nasal epilepsy ; gastric disorders ; functional heart troubles ; 
exophthalmic goitre ; vocal adductor paralysis and articulation 
defects; salivation; transitory oedema; neurasthenia, etc. Paresis 
of the soft palate and of the adductors or tensors of the vocal 



REFLEX CONDITIONS. £3 

bands is noted by Woakes ("Nasal Polypus"). Nasal cough is 
occasioned by irritation of the " sensitive areas," as pointed out 
by John N. Mackenzie and others. The patient is usually of a 
neurotic temperament, with marked nasal hyperemia. The 
irritation may originate from the contact of a probe, or, more 
properly, from the presence of hypertrophied tissue or foreign 
bodies, the latter including objects introduced, dried secretions, 
rhinoliths, and nasal tumors. 

Syncope, although very rare in operations upon the nose, 
once occurred to me while making (in a patient of the late Dr. 
W. B. Trites) an antero-posterior incision through a deviated 
triangular cartilage. The knife had just completed its work, 
and scarcely a drop of blood had escaped, when the patient (in 
the first stage of ether-narcosis, with free respiration, good pulse 
and color) suddenly sneezed and ceased breathing. Artificial 
respiration demonstrated the entire freedom of the respiratory 
tract. The pulse grew weaker and was scarcely perceptible at 
the wrist, but persistent artificial respiration, continued for 
fifteen minutes, resuscitated the boy. As soon as natural res- 
piration returned, the patient was comparatively conscious ; thus, 
there was not an overdose of ether, and absence of cyanosis 
proved that the respiratory tract was patulous. 

Nasal epilepsy may be occasioned by various irritants, 
including tumors, powders, and snuffs, and declare itself in the 
form of vertigo or complete loss of consciousness, the result of 
reflex laryngeal spasm, laryngismus stridulus, or laryngeal ver- 
tigo (which see). Aphonia is occasionally a reflex nasal symp- 
tom, as are also stuttering and stammering, spasm and neuralgia 
of the pharynx, spasm of the oesophagus (Netchayeff ), and even 
goitre (Frankel). 

Treatment. — The treatment is always to be directed to the 
seat of the trouble, irrespective of the reflex symptoms, unless 
they be of grave import, when dyspnoea, etc., should be treated 
as temporarily indicated. Remedies administered internally 
often act beneficially, but so slowly, usually, as to bring dis- 



94 DISEASES OF THE NOSE AND THROAT. 

credit upon the plan and discouragement to the patient. The 
most satisfactory measures are local, directed to the removal of 
the exciting cause, — which is generally contact between the 
turbinated bodies (usually the middle) and the septum. The 
treatment, therefore, naturally follows that noted under "Hyper- 
trophic Rhinitis." As an example, I quote from a letter from 
Dr. E. L. Mann : " In one case of laryngeal spasm (?) and cough 
the patient complained of a ' clutching feeling in the larynx,' 
which was completely relieved, after the failure of remedies, 
by an application of chromic-acid crystals to a very large anterior 
hypertrophy of the left inferior turbinated body. The peculiar 
part was, that when the acid was applied the patient complained 
of pain in the larynx and none in the nasal passages." 

(b) ANOSMIA, HYPEROSMIA, PAROSMIA. 

Anosmia (loss or impairment of the sense of smell) is due 
to various causes. While frequently central in origin, it is 
usually due to some local defect. This may consist of the par- 
tial destruction of the nerve-terminals or their involvement in a 
catarrhal, hypertrophic, or obstructive change within the nose. 
Nasal obstruction may destroy the sense of smell, by preventing 
odorous particles from coming in contact with the nerve-ter- 
minals, and the same result may follow unusual dryness of the 
olfactory pituitary membrane ; irritating, strong, or unpleasant 
odors, if long-continued ; inhalations of strong vapors ; the 
application of a strong galvanic current, caustics, or astringents ; 
the use of the nasal douche ; long-lasting catarrh ; paralysis of 
the fifth nerve, when nutrition of the Schneiderian membrane 
may be impaired ; and accidents to the head, whereby the base 
of the skull is fractured or the olfactory bulb separated from its 
branches. Anosmia may be congenital, or even hereditary ; 
there may be absence of the olfactory nerves; sometimes no 
cause can be assigned ; and, finally, it may be of purely neurotic 
origin. Temporary loss of smell is sometimes noticed in the 
first, or dry, sta^e of acute corvza. 



HYPEROSMIA. 95 

As anosmia may exist on one side only, the symptom 
may be overlooked. In making the diagnosis, one nostril should 
be carefully and completely closed while some familiar odor is 
placed near the other, — without, however, telling the patient what 
substance is used. As confusion sometimes arises, it is well to 
remember that there is a close relationship between the senses 
of taste and smell ; and when the patient is able to taste food, 
he is often led to believe that he still retains the sense of smell. 
A current of electricity may be passed through the olfactory 
nerve, which, if intact, should give rise to a phosphorescent 
odor. 

Prognosis. — The prognosis is bad if the cause reside in the 
brain ; if congenital, or due to a separation of the bulb from 
the brain, it is hopeless ; if due to catarrhal conditions, the 
cure of the catarrh may restore the function, even after years 
of loss. One case, recorded by Notta {Union Medical, July 10, 
1879), was cured after fifteen years. If due to obstruction, the 
prognosis depends chiefly upon the removal of the obstructing 
substance ; if due to paralysis of the seventh nerve, it is usually 
unilateral, and frequently curable. 

Treatment. — The treatment is both local and internal. The 
condition giving rise to it, when ascertained, is to be treated 
upon the principles stated under the corresponding subject. 
Anosmia has been occasionally " cured by the removal of an 
elongated uvula." Galvanism and faradism, applied according 
to the tolerance of the case, have been known to restore the lost 
function, and repeated attempts at the detection of pleasant 
odors may have a like influence. Where no mechanical cause 
can be found, few remedies are better indicated than amnion, 
mur., caust., hyos., ignatia, magnes. phos., natr. mur., strych., 
and sulph. 

Hyperosmia (exaggeration or overacuteness of the sense of 
smell) occurs, chiefly, in those who are hypersensitive in other 
respects, and very nervous or hysterical. Such persons often 



96 DISEASES OF THE NOSE AND THROAT. 

detect the slightest odor, even when not perceptible to others. 
The osmometer, or olfactometer, may be used to measure the 
olfactory state, in such cases. Hyperosmia should be treated as 
a condition arising from nervousness or hysteria, for which 
aeon., aurum, bell., dros., graph., hyos., ignatia, lycop., phos., 
sabadilla, sang, can., and sulph. ac. are indicated. 

Parosmia (pallesthesia, or perverted smell) has for its causes 
many of those found to originate anosmia. Parosmia is often a 
symptom of hysteria, and sometimes constitutes a form of aura 
epileptica. It sometimes occurs in pregnancy, and is not an 
unusual complication of insanity. Occasionally there exists 
some pathological alteration in the olfactory bulb or nerve or in 
the brain ; anosmia may really exist, the odor being purely of 
mental origin. 

Symptom. — Its characteristic symptom is the real or appar- 
ent presence, constantly or at intervals, of various odors, which, 
though actually present in fact, may be perverted ; thus, pleas- 
ant odors are considered very unpleasant ; the patient is sure 
he detects some disagreeable smell which is not actually present; 
or he thinks he is emitting some very offensive, pestilential, or 
deadly odor which is very unpleasant, or even highly injurious, 
to those about him. 

Prognosis. — The prognosis is bad if of cerebral origin or 
if due to atrophy of the olfactory nerve. When the result of 
obstruction or other visible pathological alteration in the nose, 
the prospects for recovery are much more nattering than when 
these changes do not exist. When a precursor of epileptic 
seizures, its cure depends upon the relief to the latter affection; 
if of nervous origin, the perverted sense can usually be relieved. 
Parosmia may be the first symptom of incipient brain-lesion or 
posterior spinal sclerosis. 

Treatment. — The treatment must depend upon the cause 
of the symptom and upon the symptomatic indications. Agnus 
c, alumina, anacard., ars., aurum, bell., bry., conium, graph., 



PAROSMIA. 97 

ignatia, kali bi., kreos., lycop., mag. phos., natr. phos., puis., 
silica, and sulph. are of value. 

Dr. Geo. Leslie {Edinburgh Med. Jour., January, 1890) has 
reported cures of facial neuralgia, odontalgia, and allied neu- 
roses by applying powdered chloride of sodium to the nasal 
mucous membrane; and I have had some agreeable surprises 
by following his suggestions. 



CHAPTER VIII. 

Various Conditions. 



NASAL HEMORRHAGE EPISTAXIS. 

Etiology. — The etiology of nasal haemorrhages is most 
varied. Primarily and directly, epistaxis may be induced by 
sudden extreme changes of temperature, ascending heights, 
sudden concussion in naval engagements, accidents, " picking " 
or " boring " at the nose, sneezing, or violent exercise. Second- 
arily, it arises from too great fluidity of the blood ; a weakened 
condition of the blood-vessels, as occurs in the so-called " bleed- 
ers," or those of a hsemorrhagic diathesis (haematophilia, pur- 
pura) ; in anaemia, either simple or pernicious ; plethora ; 
organic heart disease ; pulmonary emphysema ; degeneration 
of the blood-vessels, usually atheromatous and fatty changes 
of old persons ; ulcers or new growths ; congestion of remote 
organs, especially the liver or sexual apparatus ; in the course 
of various fevers, scurvy, or splenic defects ; and goitres or 
other tumors pressing upon the return circulation, via the jugu- 
lar veins. It may be vicarious and supplant the menstrual or 
haemorrhoidal flow, or the sudden suppression of the discharge 
from an ulcer. Martin (Annales d' Oculist ique) believes astig- 
matism to be a frequent cause of epistaxis, the result of the 
strain, especially of the ciliary muscle. According to Bosworth 
(" Diseases of the Nose and Throat"), " Deformity of the septum, 
probably more than any other single cause, gives rise to attacks 
of epistaxis." It is frequent in interstitial nephritis, but rare in 
other renal diseases. 

Origin. — The cartilaginous septum and the anterior outer 

walls are the most frequent sites; the turbinateds seldom bleed 

except from direct injury or ulceration. Personal experience 

leads me to believe that in more than 90 per cent of young 

(98) 



NASAL HAEMORRHAGE — EPISTAXIS. 99 

subjects the haemorrhage arises from the plexus of vessels near 
the centre of the triangular cartilage (the duct of Jacobson's 
organ), unless the result of accident or change of air-pressure. 
In atheromatous conditions the bleeding-point is often in the 
upper part of the nasal passages. The blood nearly always 
flows from the nose, but occasionally it is confined beneath the 
mucous membrane, giving rise to haematoma. 

Symptoms. — The symptoms which sometimes indicate an 
on-coming haemorrhage in plethoric persons are : fullness in 
the nose and head, congestion of the face, some blurring of 
vision, dizziness, and tinnitus aurium. In those in whom there 
is degeneration of the blood or blood-vessels there is rarely any 
premonition of the approaching flow. If vicarious-haemor- 
rhoidal, there may be some extra irritation in old bleeding 
haemorrhoids, but without renewed bleeding ; if menstrual, 
symptoms occur similar to those which usually precede a 
menstrual flow, especially the enlarged and tender mammae. 
The onset of epistaxis may give immediate relief to headache, 
tinnitus, and other indications of plethora ; it may be sufficient 
to remove the annoying conditions found in the habitual haem- 
orrhoidal patient ; and it may serve to relieve the menstrual 
symptoms. 

In mild haemorrhages the blood usually trickles from the 
nose in dark drops ; but when the bleeding is severe the flow 
may be quite profuse and bright red (arterial), usually the result 
of ulceration or malignant growths. It may be of short dura- 
tion and not give rise to any disturbing symptoms, or it may be 
protracted and occasion profound prostration, coma, or death. 
If long continued, the first symptoms noted are usually dizzi- 
ness and weakness ; the extremities, ears, and tip of the nose 
may become cold ; later, the patient may faint from loss of blood 
and the shock arising therefrom. This condition may end in 
coma, but rarely in death. The bleeding generally occurs from 
one nostril only, but when from both it is an indication of an 
accident, degeneration of the blood-vessels, a perforation of the 



100 DISEASES OF THE NOSE AND THROAT. 

septum narium, or the passage of blood from one nasal canal 
into the other through the post-nasal region. The blood may 
pass into the pharynx and be expectorated, giving rise to the 
fear of pulmonary haemorrhage ; inspection will, however, re- 
veal a red streak on the posterior wall of the pharynx. The 
blood is usually easily coagulable, unless it be degenerated. 

Prognosis. — The prognosis is generally good, since the 
bleeding, as a rule, stops without any treatment, and in active 
fevers and brain congestion it often affords relief and gives 
promise of a cure ; but death sometimes follows from the shock, 
the loss of blood, or obstruction of the larynx during sleep. If 
vicarious epistaxis be arrested too suddenly, either as the result 
of treatment or of cold, distressing, or even fatal, symptoms 
may follow ; nasal bleeding may betoken a grave termination 
in low grades of fever and in diphtheria ; and if the blood- 
vessels be diseased the prognosis is bad, auguring an early fatal 
termination, perhaps by cerebral haemorrhage. 

Treatment. — The treatment depends upon the condition 
present. It is first important to determine whether it be advisa- 
ble to arrest the flow, basing the decision upon the preceding 
statements. If it continue long, and the patient seem even 
slightly exhausted or nervous, it is well to proceed at once to 
arrest the bleeding. Internal remedies should be prescribed, 
and, if the case be a mild one, simple mechanical measures 
should be tested. The patient must assume the erect posture, 
as bending over, especially with tight neck-clothing, favors the 
flow of blood by aiding gravity and by preventing the return 
current through the jugular veins. Firm compression over the 
superior coronary artery, where it crosses the superior maxillary 
bone, will stop many cases. A very satisfactory method with 
children is to force a piece of paper between the upper lip and 
teeth, as near the nose as possible. Cold applications may be 
made to the nose, or to an indifferent part of the body (partic- 
ularly the wrists and back) ; and cold water may be snuffed up 
the nose. A very efficient measure, in some obstinate cases, is 



NASAL HAEMORRHAGE — EPISTAXIS. 101 

to induce the patient to stand upright, loosen all clothing about 
his neck, and hold one or both hands straight above his head. 
The inhaled air should be cool and fresh. Pressure over the 
ala of the bleeding nostril will often bring relief, as the bleed- 
ing-point is usually within the vestibule ; and pressure with the 
finger over the artery of the septum often meets with success. 
Determination of blood to the extremities, by means of ligatures 
tied tightly about them near the body, often serves a good pur- 
pose ; the same is sometimes true of hot applications to the feet 
and hands. 

After failure of some of the simplest measures, search 
should be made for the bleeding-point by means of reflector, 
nasal speculum, and cottoned probe. If the point be found, 
pressure may be exerted upon it with either the finger or a 
pledget of cotton ; personal experience, however, has taught the 
unfailing efficacy of a strong solution of chromic acid applied 
to the bleeding-point. The galvano-cautery is less satisfactory. 
As first suggested by Geneiul, lemon- or lime- juice may be 
injected into the bleeding nostril, which has first been syringed 
with warm water, that the acid may have a better opportunity 
to act. In some of the most obstinate cases, insufflation of the 
powdered leaves of the common astor (" colt's tail ") has proved 
efficient and prompt. Astringents, especially gallic acid, gallic 
and tannic acid combined, antipyrin, or cocaine, may be tried, 
but styptics are to be avoided. 

If the patient feel faint or cold, or if the pulse seem weak, 
he should be placed upon his back, and renewed efforts made 
to control the bleeding. W. W. Parker {Med. Record, October 
4, 1890) recommends the use of the following device: Fifteen 
threads of patent lint or largest spool-thread, three and one-half 
to four inches long, are doubled on themselves and tied in the 
middle with a string, the end of which should be six to eight 
inches long, for ease in removal. By the aid of a small probe 
or stick, the centre of the threads is pushed along the floor of 
the nasal fossa until it reaches the posterior naris. The probe 



102 DISEASES OF THE NOSE AND THROAT. 

is then to be carefully removed and the nostril plugged. The 
loose ends are said to act as speedy coagulators and unfailing 
haemostatics. The method is simple and essentially painless. 
In twenty-four hours the threads may be removed by gentle 
traction on the string, preceded by the removal of the anterior 
plug. 

Dr. A. A. Philip (Tlie British Med. Jour., July 18, 1891) 
advises an umbrella-plug. A piece of silk, thin cotton, or oil- 
silk is pushed well back into the naso-pharynx, along the lower 
meatus, by means of a smooth stick or pencil placed against 
the centre of the material used. When the desired introduc- 
tion is accomplished, the edges and corners of the umbrella will 
project from the nostril, when the introducer is withdrawn, and 
by it the top of the umbrella-pouch is well filled with little 
pieces of cotton. The introducer is then held firmly against the 
cotton and the umbrella-corners pulled upon so that the mass 
may tightly fill the posterior naris. The remainder of the 
pouch should next be packed, the outer portion tied (bag-like) 
with a string, and the long corners trimmed, but with the 
string projecting. When it is desired to remove the plug, open 
the bag and with forceps pick out the little pieces of cotton ; if 
no bleeding follow, the umbrella may be removed ; otherwise it 
should be repacked. If the material adhere to the membrane, 
a little warm water dropped in will readily loosen it. 

Plugs may also be inserted by the following method, or its 
modification : Antiseptic non-absorbent cotton is passed into the 
anterior naris in small pieces, packing each one with a blunt- 
pointed instrument, until the anterior cavity is quite tightly 
filled. A number of small pieces of fine sponge may be used 
instead of the cotton ; to the first of these a strong thread is 
fastened, and the others threaded on it and passed, one by one, 
into the nasal passage. Rubber or skin bags can be inserted 
through the anterior naris in a collapsed condition, and, when 
in position, inflated or filled with hot water. Ignazio Dionisio 
{Deutsche Med. Zeitung, September 25, 1890) proposes an im- 






THERAPEUTICS OF NASAL HEMORRHAGE. 103 

provement upon these by using a rubber-covered tube, which, 
when in position, does not prevent nasal respiration. Posterior 
plugging is rarely needed. It is accomplished by the aid of a 
soft-rubber tube, Eustachian catheter, or Bellocq's cannula 
threaded with a string and passed through the bleeding canal 
into the pharynx. A piece of lint, cotton, or sponge, suf- 
ficiently large to fill the posterior naris, is then tied to the 
first string and drawn into the choana. Counter-pressure is 



Fig. 35.— Eustachian Catheter. 




£~A,YA£HAUa COPtitLA 



exerted by tying a small pad of lint or cotton to the string 
projecting from the nostril. 

The objection to the posterior plug is that it may create 
considerable irritation, even ulceration, erysipelas, abscess, 
pyaemia, or convulsions; therefore, it should not remain in 
position longer than twenty-four 
to thirty-six hours, when it should 
be gently removed, after careful 
spraying to insure moisture of 
the plug and membrane. The 
nose should next be cautiously 

J Fig. 36.— Bellocq's Cannula. 

sprayed with a mild disinfectant. 

Relief has sometimes followed the application of blisters 
placed over the hepatic region, when the liver seemed to be the 
cause of the epistaxis. Transfusion of blood, saline solutions, 
or warm milk may be imperatively demanded. 

The most important after-treatment is medicinal. 

Therapeutics. 

Aeon. — With each paroxysm of cough the nose bleeds ; if 
associated with pain in the upper portion of either eye, the 
indication is more certain. Epistaxis in children. Nose-bleed 
from the effects of the sun (glonoin). 



104 DISEASES OF THE NOSE AND THROAT. 

Arnica. — Epistaxis after every exertion, following injury, or 
during low grades of fever. 

Bry. — Especially in persons under 40 years of age, as an 
empirical remedy or with the characteristic symptoms ; gastric 
derangements ; vicarious menstruation. My chief reliance is 
placed upon this remedy for passive epistaxis of young persons, 
■in whom it is almost a specific. 

Cactus. — When the result of cardiac troubles. 

Carbo veg. — In old persons who are prostrated and whose 
blood is deficient in fibrin. Face pale during and after bleeding. 

China. — Habitual nose-bleed, especially early in the morn- 
ing. Ill effects following epistaxis. 

Crocus. — " Blood thick and dark ; for acute attack and as 
prophylactic." (W. T. Helmuth.) 

Hamamelis. — Particularly in haemorrhoidal patients ; dark, 
venous, passive bleeding. A tendency to general bleeding. 
Vicarious, or even when occurring with haemoptysis. 

Ipecac. — Especially if occurring during the eruptive fevers, 
and for purpura haemorrhagica or haematophilia. 

Lach. — Especially at the menopause ; or for nose-bleed 
preceding the menstrual flow. 

Phos. — Particularly for " bleeders " and haemorrhages oc- 
curring during fevers and jaundice. 

Puis. — Passive, venous haemorrhage; often vicarious men- 
struation or suppressed menses. Varicose pharyngeal veins. 

Sulph. — " Epistaxis associated with chronic vertigo." (P. 
Jousset.) 

Trillium. — Dr. Farrington recommended this remedy in the 
tincture as a local application, first clearing out all the clots. A 
piece of cotton is to be soaked in the solution and inserted into the 
passage. 

FOREIGN BODIES IN THE NASAL PASSAGES. 

Foreign bodies are rarely found in the nasal fossae, except 
in children and insane adults. The objects oftenest introduced 
are beads, buttons, stones, marbles, glass, beans, grains of corn, 



FOREIGN BODIES IN THE NASAL PASSAGES. 105 

sticks, pieces of metal, insects, maggots, and worms (the latter 
usually crawling up from the stomach). When the result of 
accident, broken sticks, stubble, pieces of shell, etc., may find 
lodgment in the nose. Concretions and necrosed bone, when 
loose within the passage, act as foreign bodies. When vomiting, 
particles of food and ascaris lumbricoides are sometimes forced 
through the posterior nares. 

Children sometimes introduce foreign bodies accidentally, 
but usually in a spirit of playfulness, mischief, or revenge ; the 
insane often insert them as the result of an irresistible impulse ; 
and hysterical adults for the purpose of creating sympathy or 
care. These sometimes feign such accidents, but examination 
will reveal their malingering tendency. 

Symptoms. — The symptoms depend upon the size and 
shape of the body, the duration of its presence, and the normal 
nasal sensibility. If large, it may create nasal obstruction and 
loss of smell; but if the body be smooth in outline, there is 
usually little irritation; though beans, etc., may absorb moisture 
and swell, thereby producing pain. Rough substances generally 
cause considerable pain and irritation, even ulceration and 
haemorrhage. 

At first there are often itching, sneezing, and a free mucous 
discharge ; the latter may soon become profuse, purulent, cor- 
rosive, exceedingly offensive, and usually contain whitish, floccu- 
lent masses. Ulceration sometimes occurs, and perforation of 
the septum has been observed. Neuralgia may follow, or con- 
cretions form about the body, giving rise to a rhinolith ; on the 
other hand, no symptoms may occur. While in charge of the 
eye, ear, and throat department of the Germantown Homoeo- 
pathic Dispensary, I saw a woman, 62 years of age, in whose 
right nasal fossa was discovered a foreign body. This proved 
to be the cause of neuralgia, conjunctivitis, dacryocystitis, a 
superficial ulcer on the right side of the nose and cheek, and a 
considerable swelling of the naso-malar region. There existed 
a most profuse, offensive discharge from the nostril, with loss of 



106 DISEASES OF THE NOSE AND THROAT. 

nasal respiration. The lachrymal duct had been treated and a 
diagnosis of "cancer" made. 

If the nose be examined by reflected light, nasal speculum, 
cocaine, and probe, the diagnosis is not often difficult. 

Prognosis. — The prognosis is good if the secondary ulcera- 
tion be not very great and if unilateral anosmia have not 
resulted from the destruction of nerve-cells. 

Treatment. — The treatment consists in the removal of the 
body and the cleansing of the cavities of all offensive or puru- 
lent secretions. The former can be done in various ways, de- 
pending upon the size, position, and consistence of the object. 
If it be possible to remove the body by gravity, this may be 
accomplished by suddenly throwing the head forward just as a 
strong expiratory blast is forced through the nose ; or the free 
passage may be closed with the finger or thumb while the pa- 
tient forcibly exhales with closed mouth. Neither of these 
manoeuvres is of frequent utility. Some recommend that the 
free nostril be tightly closed around a soft-rubber tube, the 
operator blowing through the latter with the idea of forcing the 
object out through the nostril of the obstructed side. As yet I 
have never succeeded in this manipulation, but the following 
device seems worthy of consideration : The soft-rubber tip of a 
Politzer bag is passed into the free nostril ; the latter is closed 
around the tip, and while the patient makes a vigorous effort to 
blow, as in extinguishing a light, the bag is compressed with a 
strong, quick pressure of the hand. 

If well clown in the passage, the object may often be 
removed by a bent probe, wire, hair-pin, or hook ; but in such 
manipulations it is necessary to proceed with great care, lest the 
extraneous body be forced backward, becoming still more diffi- 
cult to remove. If a shoe-button, it is sometimes possible to 
insert a hook or the bent end of a wire into the shank. Soft 
substances may be similarly extracted, but a little scoop, curette, 
or wire loop often acts better in such instances. Forceps are 
frequently useful, but if the body slip from the grasp of the 



FOREIGN BODIES IN THE NASAL PASSAGES. 107 

closing jaws it may be forced still deeper. If necessary, the 
surface of the body may be thoroughly dried with absorbent 
cotton, and a camel's-hair brush wet with strong glue held firmly 
against the dried surface until the glue and brush have had time 
to adhere to the mass, when all may be removed, if not too 
large or too firmly imbedded. A bundle of rolled horse-hair 
may be looped and passed into the nasal passage until beyond 
the object, when, by unrolling the hairs, it is often possible to 
draw it out. By means of a diminutive Bellocq's cannula or 
catheter (see " Epistaxis "), a small pledget of cotton or a piece 
of sponge may be made to enter the posterior naris, and as it is 
brought down to the nostril it may draw the foreign body with 
it. Failing in these, there are two methods to which recourse 
may be had : first, the foreign body may be pushed into the 
pharynx, where a finger should be passed to catch the offender, 
lest it enter the larynx or oesophagus; or, second, the sub- 



Fig. 37.— Gross' Ctjkette. 

stance may be crushed by means of diminutive lithotrites, ecra- 
seur, wire snare, or very strong, small forceps, after which it 
may be removed through the nostril, — preferably by means of a 
post-nasal syringe. Projecting spiculae of bone may be cut off 
with small bone pliers or forceps. 

If the object can be firmly fixed with any of the preceding 
devices, careful traction should be exercised, effort being directed 
to the rotation of the body in such a way that it will conform 
to the proper axis of the space occupied. If this be done, little 
fear need be entertained of causing any special damage to the nose. 
There is sometimes a moderate amount of pain, requiring cocaine; 
and slight haemorrhage, which usually stops in a few minutes 
without treatment. Some writers advise the universal use of a 
general anaesthetic for children ; to this I cannot subscribe, as I 
find it rarely necessary even in infants less than a year old. 

Cleanliness and asepsis are important, following the dis- 



108 DISEASES OF THE NOSE AND THROAT. 

lodgment of any extraneous body, especially when a muco- 
purulent, purulent, or bloody discharge exists. 

It is not often necessary to give internal remedies to reduce 
the inflammation prior to the removal of the object, but aeon., 
hepar, silica, and sulph. may be indicated as after-treatment. 

RHINOLITHS (NASAL STONES) AND CALCIFICATION OF THE MUCOUS 
MEMBRANE OF THE NOSE. 

Rhinoliths consist of the formation of concretions within the 
nasal channels or accessory cavities. These nasal stones usually 
have some small substance as a nucleus, around which they 
form by a gradual calcareous deposit, consisting of about 80 per 
cent inorganic and 20 per cent organic material. The nucleus 
may be a cherry- or small gravel- stone, a bead, bean, or even 
a small mass of inspissated mucus. A gouty deposit may be 
the starting-point. Rhinoliths vary greatly in size ; they may 
be very small, or almost fill the nasal fossa. 

Symptoms. — The symptoms are not different from those 
noted under " Foreign Bodies," except that external deformity is 
occasionally present, and in Hendley's case an external sinus 
formed. Occasionally, extensive ulceration supervenes, the 
septum is perforated, and the turbinateds atrophy. Facial 
paralysis, ptosis, and epiphora may result. 

Treatment. — The treatment is that referred to under the 
foregoing subject, but the rhinolith is more apt to require 
crushing. Unlike other foreign bodies, rhinoliths are some- 
times deeply imbedded or encapsuled in the mucous membrane, 
when it is necessary to loosen them with a probe, curette, or 
spoon before they can be removed. 

Calcification of the mucous membrane is very rare ; it is 
usually found in elderly persons, but may occur in children of a 
gouty or calcareous constitution. The affected parts are white 
and hard to contact. Usually, nothing is called for in the way 
of treatment. Remedies are to be prescribed as indicated for 
catarrhal, ulcerative, or other pathological complication or sequel. 



CHAPTER IX. 

Nasal Tumors. 

Although tumors which affect the nasal cavities are usually 
primary, they are not infrequently secondary to neoplasms in 
some other part of the body ; when so, they usually attack the 
nose by continuity, but occasionally by metastasis. These 
growths often extend from the nose to the face, mouth, pharynx, 
or accessory cavities. As a rule, they are benign ; malignant 
nasal tumors are rare. The benign growths are mucous and 
fibrous polypi, papillomata, cysts, angeiomata, enchondromata, 
osteomata, and exostoses ; the malignant, sarcomata and carci- 
nomata. 

Myxomata (mucous polypi) are the most frequent of the 
nasal growths ; others are rather infrequent, although a slight 
exostosis is often encountered, but those sufficiently large to 
demand operative interference are unusual. 

Benign Growths, 
mucous polypi myxomata. 

Etiology. — As a rule, these growths start as sessile bodies 
and, as they grow, generally form a pedicle, the mass of the 
growth hanging down in the form of a pear. Mucous polypi 
usually spring from the middle turbinated body or its immediate 
surroundings; less frequently from the septum, and perhaps 
never from the superior or inferior turbinateds. They occa- 
sionally find origin in the accessory cavities and upon the 
bulbous and hammular processes of the ethmoid bone. 

It is probable that they develop from a catarrhal or other 
irritation of the Schneiderian membrane. In some instances a 
very tortuous and narrow canal seems to act as an excitant in 
the development of mucoid polypi ; heredity is a probable factor, 
and a polypoid diathesis is not out of the question in considera- 

(109) 



110 



DISEASES OF THE NOSE AND THROAT. 



tion of the numerous instances in which the ears, the uvula, 
the uterus, etc., share in the process. Although Woakes, in his 
"Nasal Polypus," asserts the invariable association of nasal 
polypi with necrosing ethmoiditis, I must confess to very rarely 
finding this relationship; but believe such ethmoidal changes 
the result, not the cause, of the neoplasm. While mostly an 
affection of adults, children occasionally suffer. 

Mucous polypi are chiefly composed of a layer of fibrous 
tissue, the sac, in which is con- 
tained the growth proper, com- 
posed of some fibres of this in- 
vesting tissue, together with a 
large amount of mucous and fat 
cells, glandular tissue, and blood- 
vessels. They often develop 
rapidly and have a decided tend- 
ency to recur, even after repeated 
removals, thus not only dis- 
couraging the operator, but dis- 
heartening the patient. Since 
the introduction of improved 
methods of operation the results 
are much better, though repe- 
tition of extirpation is not infre- 
quent. Myxomata may be said 
to consist of two varieties, — true 
mucous growths and those which 
resemble adenomata, — but for practical purposes this distinc- 
tion need not be made. The former may contain cysts, the 
latter not. Fibrous polypi may be associated with the mucous 
variety. 

Myxomata vary in size from a mere granule to masses four 
or five inches long, filling the nasal cavity and extending from 
the pharynx to the nostril. Occasionally they are chiefly post- 
nasal. Although they sometimes occur singly, they are usually 




Fig. 38.— Myxomata. (From a retouched 
photographic negative.) 



MUCOUS POLYPI — MYXOMATA. Ill 

manifold and hang from the upper portions of the nasal cavities 
like bunches of grapes, or, more strictly, clusters of pears. They 
present the appearance of glistening white or gray masses, and 
are sometimes mistaken for lumps of mucus. MacDonald (" Dis- 
eases of the Nose ") says they are pinkish, bluish, and sometimes 
grayish or yellowish. They are easily indented with a probe, 
which temporarily destroys the light reflex, but the pitting soon 
passes off and the gray aspect returns. When large enough 
to project from their original bed, their mobility may be easily 
demonstrated by the aid of a probe. Their points of attach- 
ment, likewise, may be frequently located. 

Symptoms. — The symptoms of the smaller growths are often 
so slight that the patient makes no complaint ; but those of large 
growths are quite characteristic, namely, obstructed nasal res- 
piration ; " nasal " speech ; profuse discharge of thick mucus, 
having a very musty, pungent odor ; and loss of smell, partial or 
complete. In the early stages and in clear weather no symp- 
toms may be present, but dampness may so distend the mucous 
membrane as to cause difficult nasal respiration. The voice is 
affected in proportion to the amount of obstruction ; sneezing is 
an occasional symptom of the early stage only. In severe cases 
it is not unusual to find the face broadened, the result of dis- 
placement of the nasal bones, due to lateral pressure exerted by 
the growths ; the turbinateds are often partially, rarely com- 
pletely, absorbed ; and the mucous membrane is sometimes 
degenerated. When the nasal channels are completely ob- 
structed anosmia is noted, but that defect may arise before this 
stage is reached. In some instances taste is impaired or even 
lost. Headache, either frontal or occipital, is often present. 
Dizziness, loss of memory, and aprosexia may follow. 

Diagnosis. — The diagnosis, as suggested, is usually easy, 
but occasionally the tumor is hidden by overhanging or inter- 
vening ledges or prominences, normal or pathological ; on that 
account the lining membrane should be thoroughly cocainized 
where, on account of reflex nasal symptoms, the peculiar voice, 



112 DISEASES OF THE NOSE AND THROAT. 

the characteristic odor, etc., polypi are suspected. After the 
shrinkage of the tissues, one will rarely fail to discover even very 
small growths. Occasionally, where suspected, polypi may be 
discovered by passing a bent probe, as suggested by Dr. C. M. 
Thomas, into the middle meatus, dislodging them from their beds. 

Zuckerkandl describes a rare condition: a cysto-pneumatic 
expansion of the middle turbinated bone, sometimes associated 
with mucous polpi. 

Prognosis. — The prognosis is good, although anosmia is at 
times permanent. In some cases the deformity (" frog-face ") 
cannot be relieved, and it is possible that a mucous polypus 
may degenerate into a sarcoma or carcinoma, with which it is 




E.A.YARNALL PHIL A. 




Fio. 39.— Sajous' Snare, with Three Tips. 

sometimes associated. Browne (" Diseases of the Throat and 
Nose ") reports the cure of a glaucoma by removal of a polypus 
in a case which iridectomy had failed to relieve, and cases of 
unilateral blindness have been described as cured after the re- 
moval of mucous tumors of the nose. Goitres and Graves' 
disease have been reported cured and caused by removing nasal 
polypi. If the growth originate in one of the accessory cavities, 
the prognosis must be guarded. Spontaneous cure is rare. 

Treatment. — Although remedies alone sometimes cure, it is 
usually necessary to supplement them with mechanical or sur- 
gical measures. No instruments are so satisfactory as snares. 
In using them the growth should be surrounded as near its base 
as possible, when, by tightening and pulling upon the wire loop, 



MUCOUS POLYPI MTXOMATA. 113 

the polypus is either cut off or torn away. For this purpose 
Sajous' snare is usually the most satisfactory ; it can be intro- 
duced concealed, and when in position the loop protruded. 

Dr. W. E. Casselberry (N. Y. Med. Jour., November 14, 
1891) advises breaking or cutting off the an tero-inferior portion 
of the middle spongy bone in order to get into the middle meatus 
more rapidly, if in any case this cannot otherwise be accom- 
plished, where the polypi are attached to the margins of the 
hiatus semilunaris. This has been advocated by a few others, 
but most rhinologists do not advise it. 

Polypi which project into the naso-pharynx may be re- 
moved by curved tube-attachments, as usually made with 




Fig. 40.— Wright's Snare. 



Jarvis', Sajous', and Wright's snares ; on the other hand, these 
growths can often be grasped with Jarvis' or Mackenzie's 
straight snare, passed through the nose, or by the post-nasal 
forceps recommended under "Adenoid Vegetations." 

To a few operators, the most satisfactory method of removal 
is by means of the galvano-cautery wire. The platinum or, 
better, Glitsmann's platinum and iridium loop is passed around 
the pedicle, if possible ; when in position, the wire is to be 
tightened until it grasps the tumor or pedicle quite firmly ; the 
circuit is then completed, and the growth divided by gradually 
lessening the loop. In this operation the chief difficulty encoun- 
tered is in surrounding the pedicle ; this accomplished, the 



114 DISEASES OF THE NOSE AND THROAT. 

results are very satisfactory, although personal experience greatly 
favors a careful and thorough removal with the cold wire. 

Electrolysis is sometimes efficient. A large-sized, gold- 
plated or zinc needle, attached to the positive pole of a galvanic 
battery, is to be passed into the mass, and the negative sponge- 
electrode applied over the nose ; the circuit is then completed 
and the current continued for from ten to fifteen minutes. 
After a few repetitions the polypus will generally shrivel and 
drop off. 

Caustics or coagulants are occasionally useful in destroying 



O 




Fig. 41.— Mackenzie's Cog-wheel snare. 



the growth ; a drop or two of pure carbolic acid, preferably, 
may be injected or forced into the most dependent part of the 
tumor, either by means of a hypodermic syringe or the sharp 
point of a glass rod. Care should be exercised not to use too 
much acid, lest severe reaction follow ; nor must more than two 
or three polypi be treated at a sitting. The acid causes the 
mucin to coagulate ; as a result, the growth frequently shrivels 
and disappears in a few days, though several injections may be 
demanded. In place of the carbolic acid, a few crystals of 



MUCOUS POLYPI MYXOMATA. 115 

chromic acid can be fused on a probe and passed into the 
tumor. Glacial acetic acid is often used in solution, but it 
'requires repetition every four or five days. All acid applica- 
tions, however, have the disadvantage of causing a possible 
septic focus by their action on the polypus. 

Cocaine, in a 4-per-cent solution, should be used in the 
nasal fossa before any operation on its tissues : first, to control 
pain ; second, to allay the fears of the patient ; third, to allow 
more room for the employment of instruments ; and, fourth, for 
the purpose of lessening primary haemorrhage. 

Formerly, nasal polypi were generally removed with for- 
ceps ; and, while this is the method still sometimes employed, it 
is usually very bloody and painful and, unless performed under 




Fig. 42.— Caughtry's Light Angular Forceps. 

good illumination, often results in much loss of normal tissue. 
Light forceps and a small hook are often very useful aids in 
encircling the growth with a wire loop. Although the usual 
advice is to touch the point of former attachment with acid, 
caustic, or cautery in order to prevent recurrence, my results 
have greatly improved since discontinuing such irritating 
measures. Dr. E. Harrison {Jour. Resp. Organs, August, 
1890) advises frequent after-spraying with witch-hazel or 
alcohol. 

The best plan is to remove all of the polypi within reach, 
repeating the process in about ten days, and so continuing until 
all have fallen from their pent-up position. The patient is then 
carefully examined every month for a year, if possible, after 
which a cure is usually well established. 



116 DISEASES OF THE NOSE AND THROAT. 

In addition to the mechanical means referred to, treatment 
should be directed to the catarrhal condition upon which the 
growths sometimes depend ; but this can be done satisfactorily 
only when the nasal passages are quite free. The use of pow- 
ders (for example, sang. can. and lycop.), long ago recom- 
mended by the early followers of Hahnemann, has some 
advocates. 

Dr. Wm. It. King told me that his best results had been 

obtained by blowing powdered sang. nitr. 2 x on the growth, 

as an adjunct to the internal remedy, which was most frequently 

sang. can. 3 x. 

Therapeutics. 

Calc. carb., persistently employed, is Jousset's " most use- 
ful drug." 

Calc. phos. — " Large polypi of both passages, gray in 
color and bleeding easily. When the growths are small, they 
are absorbed ; when large, they are detached. Four weeks are 
sufficient for such results." (Charge.) 

Kali nit. — "A polypus filling the whole right side of the 
nose was entirely cured by the 3 x." (T. F. Allen.) 

Sang. can. — Looked upon by many as the remedy for the 
cure of mucous polypus, but I must confess to many disappoint- 
ments and no marked cures ; it has, however, seemed to prevent 
recurrence after mechanical removal. It has been used locally 
and internally. One of its chief indications is: "Mucous polypi 
bleed profusely." 

Thuja, nit. ac, phos. — Polypi associated with profuse haem- 
orrhage. 

Wyethia. — A letter from Dr. E. Lippincott contains the 
following : " From the result of treatment, I am inclined to 
believe that Wyethia H. will cure nasal polypi, and be one of 
the leading remedies in almost any disease of the air-passages 
having its origin in catarrh." 

Compare alum., coni., fer. phos., kali bi., sulph., and teucr. 






FIBROUS POLYPI FIBROMATA. 117 



FIBROUS POLYPI FIBROMATA. 



Etiology. — The cause of this affection resides in the highly 
vascular character of the nasal mucous membrane. It is usually 
found in males from 15 to 30 years of age. In the early 
stage it is not always possible to distinguish between mucous 
and fibrous polypi, but later the difference becomes marked. 
Fibroma is so hard that it cannot be indented with a probe ; it 
is rarely pedunculated, and, if so, the pedicle is very short and 
broad. Its color is that of the surrounding mucous membrane, 
or even a darker red. It is glistening and quite irregularly 
lobulated. The points of origin are similar in the two forms, 
but fibrous polypi are usually situated more posteriorly. They 
spring from the periosteum, or even from the bone itself, and 
not, as the mucous growths, from the mucous lining. The in- 
vesting membranous sac is of the same character in each, but 
the central structure is very different. In this form it is chiefly 
fibrous, with numerous cells and nuclei and enlarged vessels. 
Fibrous polypi often originate in the naso-pharynx, but rarely 
in the accessory cavities, although they may find their way to 
them after partially filling the nasal spaces. Fibromata not only 
frequently dislocate the nasal bones, but push aside all structures 
which presume to bar the way. Their growth is usually slow, 
and they may be years in assuming serious proportions. 

Symptoms. — The early symptoms are similar in the two 
affections ; but when the fibroma is large enough to cause pain 
and produce obstruction to nasal respiration, this defect is almost 
constant and is not materially influenced by damp weather ; nor 
does position of the head or blowing the nose favor or obstruct 
nasal respiration as in mucous growths. The face early assumes 
the characteristic "frog" form, due to dislocation of the nasal 
bones. When it fills the nasopharyngeal space, more or less 
completely, there may be drowsiness and sleepiness ; cerebral 
symptoms are sometimes present, and death may result from 
brain involvement. The slight ulceration which sometimes 



118 DISEASES OF THE NOSE AND THROAT. 

occurs gives rise to frequent, even dangerous haemorrhages. 
Happily, this form of polypus is rare. 

Hydro-encephalocele (hernia of the brain through the 
cribriform plate of the ethmoid) may resemble a fibrous polyp, 
but the former affection is congenital, soft, and, according to 
Spencer Watson, a pulsating mass. 

Prognosis. — The prognosis of fibrous neoplasms depends 
upon the general constitutional peculiarities of the individual, 
the size and situation of the growth, and the treatment adopted ; 
but spontaneous cure occasionally occurs. On the other hand, 
there exists the rare possibility of a cancerous degeneration, 
brain involvement, and death from repeated haemorrhages or 
septicaemia. Holger Mygind, of Copenhagen ( Ann. Univ. Med. 
Sri., 1889), reports a case at first sarcomatous, later fibro-sarco- 
matous, and finally fibrous. Fibrous growths may be compli- 
cated with myxomata, adenomata, chondromata, and osteomata. 
If the growth be early diagnosed and treated, it is usually pos- 
sible to destroy it, but recurrences are frequent. 

Treatment. — In the early stage, electrolysis and galvano- 
cautery puncture are the most promising mechanical measures, 
but when the tumor has assumed greater proportions the 
galvano-cautery snare is usually more appropriate. In its 
absence the cold- wire snare, if made to cut slowly, will answer; 
otherwise the haemorrhage is very severe, even fatal. The treat- 
ment may consist of strangulation with a ligature, but this is 
unpleasant, owing to the offensive odor ; it is also dangerous, as 
it has led to septicaemia. Medicines, internally administered, 
sometimes afford decided relief, and may even render recourse to 
operation unnecessary. The usual means adopted for the re- 
moval of these growths, including electrolysis, occasionally fail, 
owing to their great size ; it will then become necessary to re- 
sort to one of the more formidable operations of turning back 
or splitting the nose, in order to gain free access to the nasal 
cavities. This may be accomplished by one of the following 
operations : Oliver's, Rouge's, Cassaignac's, Barascz's, or one of 



PAPILLOMATA. 119 

their various modifications. It is not the province, however, 
of such a work as this to enter into a description of those 
methods which belong to the domain of general surgery. The 
nasal fossae once freely opened, the operation is best completed 
by the assistance of a needle passed through the tumor, around 
which a galvano-cautery loop is to be passed. It is better to 
use a hot wire, as the cold snare is apt to cause very severe 
haemorrhage : the same objection applies to the knife and forceps. 

Therapeutics. 

Conium. — Fibrous polypi, which prick and itch after prob- 
ing ; burning, stinging pains in nose ; discharge purulent and 
bloody. 

Compare calc. carb. and silica. 

PAPILLOMATA. 

Warty growths are rather infrequent, but are occasionally 
noted in the nasal passages of children and young adults. They 
may be hard or soft, chestnut-colored or raspberry-like, and 
are usually attached to the septum by a broad base ; they may, 
however, spring from the lower turbinated body, directly within 
the vestibule. 

Pathology. — Pathologically, they are not unlike cutaneous 
warts, although they have a mucous covering. Unlike mucous 
polypi, they seldom recur after removal. Care must be exer- 
cised not to mistake them, on the one hand, for carcinoma, which 
has a broad base and bleeds easily ; or, on the other, for a 
roughness which sometimes occurs in the later stage of chronic 
catarrh. 

Symptoms. — Their symptoms are common to many catarrhal 
conditions of the nose, and not such as to lead to a diagnosis 
without inspection. Irritation stands first in the list ; this may 
give rise to reflex cough, sneezing, and acrid discharge. It is 
unusual for a papilloma to become large enough to interfere 
with nasal respiration or cause nasal asthma. 



120 DISEASES OF THE NOSE AND THROAT. 

Treatment, — Warty growths sometimes yield to the use of 
internal remedies ; where these fail, the neoplasm can be 
destroyed by the galvano-cautery point or one of the acids 
recommended under " Hypertrophic Rhinitis " ; but mono- and 
tri- chloracetic acids act too slowly to be satisfactory. Moder- 
ately large growths are best removed with the snare. 

The chief internal remedies are ars. alb., nitric acid, 
sang, nit., and thuja. 

ADENOMATA. 

Glandular tumors are rarely found in this locality, and it 
is doubtful whether the few reported cases will stand the test of 
careful pathological investigation, as it will most likely be found 
that the glandular structure is a part of a sarcoma, carcinoma, 
fibroma, etc. 

ABSCESSES. 

Abscess of the septum is usually due to injury or some 
profound systemic poison. The condition is rare. It may be 
acute or chronic. The symptoms are those of pus collections 
generally. Respiration is rarely impaired. It is diagnosed by 
its bilateral, rounded projection, and by distinct fluctuation. 
Hsematoma and hyperplasia and engorgement of the tissues 
covering the triangular cartilage must be excluded. 

The prognosis is good; for, even when the triangular 
cartilage is perforated, no external disfigurement follows. The 
bone is rarely, if ever, necrosed. 

Treatment consists in the use of hepar and silica internally ; 
if these fail to give early relief, the sac should be incised on one 
side only. 

H^EMATOMATA. 

Blood-tumors of the septum are usually traumatic. They 
closely resemble abscesses, but the mucous covering is of a deeper 
color — even purple — in haematomata. 

The prognosis and mechanical treatment are those of 
abscess, but recently Ricci {Jour. Lar. and Rhin., September, 



CYSTS — ANGEIOMATA. 121 

1890) perforated the mucous membrane beneath the upper 

up. ^ 

The internal remedies are arn., crotalus, ham., lach., and sil. 

CYSTS — CYSTOMATA. 

Cystic tumors of the nasal cavities are very rare, and 
usually arise from the adenoid tissue of this region. They 
closely resemble mucous polypi, but are usually darker in color, 
less glistening, not so movable, and occur singly. Cystic tumors 
contain a clear, colorless fluid ; if the sac be opened or torn, the 
tumor at once collapses and is not prone to recur. 

The symptoms are not in the least characteristic of the 
affection, and are analogous to those of papillomata, with the 
absence of the irritating discharge. The prognosis is good. 

Internal remedies seem to have little effect, but evulsion, 
incision, or galvano-cautery acts promptly. The sac may be 
ruptured if the nose be blown vigorously or the patient sneeze 
violently. The usual remedies are apis, apoc, ars., and sil. 

ANGEIOMATA. 

Vascular tumors of the nose are quite rare. I have seen 
but one case, which was diagnosed microscopically by Dr. C. 
V. Vischer, thus making the eleventh recorded case. To these 
Dr. H. P. Bellows has just added a twelfth (see forthcoming 
Trans. Amer. Inst. Horn, and Jour. Oph., Otol., and Lar.). 
Operations upon these growths are usually followed by free 
primary and often secondary bleeding. 

The prognosis is not always good. Although others, with 
the exception of Dr. Bellows, have noted no tendency to recur- 
rence after removal, the case upon which I operated showed 
evidences of recurrence in less than one year, and is at present 
undergoing treatment at the Hahnemann College Dispensary 
of Philadelphia, under the care of Dr. I. G. Shallcross. Dr. 
Bellows cured the secondary growth in his patient, by the. local 
use of a saturated solution of kali bi. 



122 DISEASES OF THE NOSE AND THROAT. 

ENCHONDROMATA. 

Cartilaginous tumors are not so rare as either papillomata or 
cysts. They usually grow from the septum, less frequently from 
the floor of the nasal chamber ; in exceptional instances they 
develop in the accessory cavities. As a rule, these overgrowths 
of the normal cartilaginous tissue give rise to no inconvenience, 
although they may slowly increase in size until nasal respiration 
is impaired, and pain, sneezing, and nasal voice become annoy- 
ing. If both nasal passages be obstructed, mouth-breathing will 
be necessitated and asthma may follow. If the unaffected side 
have free respiration, the symptoms are almost overlooked until 
some catarrhal or other swelling obstruct the free passage and 
occasion annoyance. 



ET.A. YARN AIL Phi. 




Fig. 43.— Nasal saws. 



Enchondromata are usually of slow growth when they 
arise from a cartilaginous base, but if they spring from bone 
they increase rapidly and often undergo a sarcomatous degen- 
eration. If of rapid growth, ulceration frequently arises as a 
result of pressure, or, as with polypoid growths, deformity may 
occur and the collateral cavities become implicated. Removal 
of a simple enchondroma is usually equivalent to a cure, but not 
so with the rapidly-growing variety, which usually returns after 
removal. 

In general, enchondromata are somewhat round and the 
color of the normal mucous membrane. They are so hard that 
a needle cannot be forced into them without effort. When they 
spring from the septum they may resemble spicules of bone 
projecting toward or even into the opposed turbinated body. 



OSTEOMATA. 123 

Treatment. — Unless enchondromata interfere with respira- 
tion or vocal resonance, or cause pain, reflex, or catarrhal symp- 
toms, it is not advisable to disturb them. If situated in the 
lower portion of the canal they can be sawed off, or, when trans- 
fixed with a needle, cut off by a loop of wire, either hot or cold. 
Considerable time should be consumed in their removal with the 
cold wire. If very large and situated in the roof of the nasal 
cavities, it may be found necessary to resort to one of the opera- 
tions suggested for the removal of large fibrous tumors from that 
region. In operating upon cartilaginous growths in the nasal 



E&yABWULF/llLA. 

Fig. 44.— Jarvis' Transfixing Needles. 



vault, one should bear in mind the close proximity of the brain, 
the bony floor of which may have been absorbed by the pressure 
of the tumor. 

OSTEOMATA. 

It is important that bony tumors be carefully distinguished 
from exostoses, which occur very frequently in the nasal pass- 
ages. Osteomata are quite rare, and are the result of ossifica- 
tion in the newly- formed connective tissue; unlike exostoses, 
they usually originate in the mucous membrane. Bony growths 
are nearly always pedunculated and freely movable, but, like 
exostoses, they are the color of the surrounding membrane. In 
either instance, it is usually impossible to introduce a needle 
into the body of the tumor, but the pedicle of the osteoma is 
usually so soft that it can be readily divided with forceps, snare, 
saw, or cautery loop, and occasionally with scissors. Sponta- 
neous separation of the pedicle has sometimes occurred, giving 
rise to a dead osteoma. The tumor proper is usually so hard as 
to merit the name " ivory-like." 

If small, there are rarely sufficient symptoms to attract the 
patient's attention ; if large, it may press upon the opposite side 
of the canal and cause erosion and a bloody or ichorous dis- 
charge. Osteomata may grow to such a size as to invade neigh- 



124 DISEASES OF THE NOSE AND THROAT. 

boring structures and give rise to marked deformity. After 
removal there is little tendency to recur. 

The remedies suggested are calc. carb., fluor., hecla, iod., 
mere, phos., silica, and sulph. 

EXOSTOSES. 

Osseous outgrowths spring from the bony walls, — as a rule, 
from the septum. They project in the form of a spur or shelf 
of hard, bony tissue, occasionally so large as to press upon the 
structures on the opposite side of the nasal canal, but generally 
they are quite small and self-limiting. Most exostoses are of 
ivory hardness, being devoid of cancellous tissue ; but the softer 
projections usually contain some of this structure within their in- 
terior. They may return after removal, but there is no tendency 




Fig. 45.— Teets' ISasal, Bone-Forceps. 



to degeneration. Malnutrition seems to play an important part 
in their formation. 

Symptoms. — Frequently there are no symptoms indicating 
the presence of an exostosis, but it may reach such dimensions 
as to occasion pressure-pain, reflex asthma, or even obstructed 
respiration. The septum is sometimes thickened or forced into 
the opposite fossa. 

Treatment. — Medicines have not proved useful in combat- 
ing these bony outgrowths ; so that their removal depends 
upon surgical measures. It must be remembered, however, that 
there are comparatively few cases that require treatment. The 
septal saw (preceded by the use of cocaine or, in very nervous 
subjects, a general anaesthetic) will be found the most useful 



EXOSTOSES. 



125 



instrument in removing these projections. The haemorrhage is 
rarely profuse, and, if anything be required, can usually be 
controlled by pressure. 

When the spur of bone is small Teets' nasal bone-forceps 
will usually be sufficient, but, on account of the density and 
hardness of the exostosis, it may be necessary to resort to the use 
of trephines or burrs. For this purpose the dental engine acts 
well, but the electric motor will rotate the drills with greater 
precision and regularity. 

If the exostosis be large, it is often better to turn the mucous 
membrane and periosteum back before the saw is introduced, — 



I I f 



I 



B i 



i : 



Fig. 46.— Burrs and Trephines. 



an unnecessary precaution with small growths. If the trephine 
or burr of the dental engine or electric motor be used, the cover- 
ing of the growth should be divided and the point passed through 
the incision. If the burr rotate quite rapidly, the soft tissues 
escape much injury while the hard bone is speedily reduced. 
The haemorrhage is quite profuse for a time, but is easily con- 
trolled by pressure. Electrolysis is strongly advised by Drs. 
Moure and Bergonie, and has acted well for me. Both mono- 
polar positive and bipolar galvano-puncture have been em- 
ployed. Sail-makers' needles (of steel) are best for the purpose. 
C. H. von Klein {The Times and Register, November 23, 



126 DISEASES OF THE NOSE AND THROAT. 

1889) has devised nasal bone-forceps which make the section 
from below, leaving the membrane intact above ; by the aid of 
forceps the severed spur or ridge is removed, when the mem- 
brane is to be gently pressed into position, where it promptly 
unites. The galvano-cautery and acids act well for small 
exostoses. 




Fig. 47.— Vox Klein's Nasal Bone-Forceps. 



Malignant Tumors. 

sarcomata. 

Sarcomata appear either as primary or secondary growths. 
They consist of round or spindle cells, either small or large, and 
are quite soft and exceedingly vascular. In some instances 
they extend from surrounding tissues and involve the nose by 
continuity. They are malignant in nature, and usually re-form 
rapidly after removal. While there is generally the underlying 
cancerous cachexia, these tumors sometimes result from the 
degeneration of benign growths. 

Symptoms. — In the early stages nasal obstruction and pain 
are the chief symptoms, but soon superficial ulceration, offensive, 
ichorous discharge, and headache are noted ; the accessory 
cavities often being early invaded. Later, deep ulcerations 
occur and involve the surrounding parts by extension ; the 
features may be distorted, or the growth extend to the brain 
and speedily terminate life. 

Diagnosis. — The diagnosis is generally easy, owing to the 
decidedly characteristic indications. Sarcoma presents a bluish- 
gray appearance, is soft and doughy to the probe or finger, and 



SARCOMATA. 127 

bleeds easily, sometimes profusely, from ulcerative destruction 
of the blood-vessels. The tumor is always pedunculated, and, 
consequently, quite movable. 

Prognosis. — The prognosis should be guarded, although 
statistics would seem to prove that when thoroughly removed 
nearly 50 per cent recover ; but in some of these cases the time 
elapsing after the operation was too short to determine a cure. 

Treatment — Their total ablation is usually difficult and, 
indeed, often impossible. In the homoeopathic materia medica, 
however, there are remedies capable of relieving nearly all 




Fig. 48.— Melanosaecoma of the Nose.* 

cases, and of curing some that seemed hopeless. Owing to the 
rapid growth and difficulty in radically removing nasal sarco- 
mata, it is important to do all that can be done, in the way of 
remedies, to control the growth as well as to alleviate the dis- 
tressing symptoms. Among adjuvants, nothing seems better 
than actual cleanliness of the affected parts, especially by the 
aid of sprays of eucalyptol, cosmolin, etc. A spray composed 
of hydrastin and cosmolin (as prepared by Buffington, of Wor- 
cester, Mass.) is not only very soothing and cleanly, but has a 
decidedly healing effect, on account of both its ingredients. If 
the discharge be very offensive, a drop or two of carbolic acid or a 

* See the case reported by Dr. I. G. Shallcross, Hahnemannian Moiithly, January, 1892 ; 
also, Trans . Homoco . Med. Soc. Pa., 1891. 



128 DISEASES OF THE NOSE AND THROAT. 

small quantity of thymol may be added to the spray. When 
there is severe pain, cocaine often mitigates it temporarily and 
may control the bleeding, but is apt to increase both secondarily. 
A 20-per-cent calendula solution often acts very satisfactorily. 
Bosworth (Amer. Lav. Assn., 1890) says that, in his experience, 
sarcoma is best treated by mild measures. A radical operation 
is doubtful ; he, therefore, advises its removal piecemeal, prefer- 
ably by the cold snare. 

The remedies are noted at the close of the chapter. 

CARCINOMATA. 

Cancerous growths of the nose are quite infrequent ; they 
are rarely primary, usually extending from neighboring tissues. 
The causes and pathology are the same as when carcinomata 
occur elsewhere ; likewise the pain and haemorrhage. 

Symjrfoms. — The symptoms are not very different from 
those recorded under "Sarcomata," but the pain, although 
occasionally absent, is often more severe, lancinating, and con- 
tinuous. The growth appears as a pimple, which later becomes 
a general swelling, inducing obstructed nasal breathing ; the 
discharge is usually fetid and ichorous, and haemorrhages are 
frequent. The cancerous cachexia is at times an early symptom. 

Prognosis. — The prognosis is very grave, but an occasional 
cure is recorded. The average duration of life is about three 
years. 

Treatment. — The treatment is similar to that recommended 
for sarcomata. Although many advise removal of these growths, 
it seems better, in most cases, not to attempt it, as the entire 
cavity may be refilled in two or three days ; and, further, oper- 
ative interference often hastens the fatal termination. Conserv- 
ative treatment, by the use of sprays of cleansing and disinfect- 
ing fluids and internal remedies, will do much to alleviate the 

suffering. 

TherajDeutics of Malignant Tumors. 

Alcohol, if run up to a high potency with pure water, Dr. 

M. Macfarland claims, will speedily cure the pains of cancer. 



THERAPEUTICS OF MALIGNANT TUMORS. 129 

Alumen. — Sanious discharge, especially during the ulcer- 
ative stage. 

Ars. alb. — Burning, stinging pains ; ulcer of right ala ; 
ichorous, sanious, fetid, excoriating discharge ; marked prostra- 
tion and debility (ars. iod.). 

Aurum met. — Pus greenish, ichorous, putrid. Bruised, 
shooting, drawing pains. 

Carbo an. — For the offensive odor and in the aged. 

Conium. — In the early stage, especially if caused by con- 
tusion ; glandular deposit. 

Cundurango and galium aper. — During ulceration ; espe- 
cially for the stinging, burning pains. 

Ergot, locally applied, will very often relieve the offensive 
discharge. 

Hydr. can. — During degenerative softening. 

Kali sulph. is recommended by Schiissler for nasal epi- 
thelioma. 

Kreos. — Profuse dark-bloody, ichorous discharge ; intense 
burning. Epithelioma of the right ala. 

Lapis alb. — Before ulceration. 

Tarentula. — Especially for sarcoma, where W. S. Searle 
strongly praises it {Jour. Oph.. Otol., and Lav., January, 1891). 

Thuja. — Cauliflower excrescences; fungoid cancer. 



CHAPTER X. 

Defects in Bones and Cartilages. 



DISLOCATION OF THE BONES AND CARTILAGES. 

Dislocation of the nasal bones is quite rare. The vomer 
can be dislocated from the frontal bone and the nasal plates of 
the superior maxilla by strong lateral blows only. 

The diagnosis is easy ; the deformity occurs as a lateral 
sinking. The dislocation is reduced by means of a probe, 
straight catheter, or lead-pencil introduced into the canal, by 
which the bone is elevated into position, where it usually 
remains; it may, however, require some internal packing, as 
recommended under " Fracture of the Nasal Bones." 

Dislocation of the triangular cartilage is a much more fre- 
quent accident, and one which gives rise to greater annoyance 
and disfigurement. When replaced, the cartilage is apt to slip 
out and to interfere with respiration. On that account, it is 
usually better to treat it as recommended after the division of a 
deviated septum. 

Dislocation of the columnar cartilage is very unusual. It 
gives rise to visible deformity, in that the horizontal columnar 
cartilage is slipped from its attachment to the anterior extremity 
of the triangular cartilage, giving rise to a marked prominence 
in the septal side of the nostril into which the cartilage slips. 
Bosworth has reported two cases, and I had one some years 
ago. 

The treatment in these three cases was the same, namely, 
the cartilage was dissected out and the lips of the incision 
united with fine sutures. The results were satisfactory. ■ 

Internal remedies are little called for, but aeon., apis, 
bell., fer. phos., or hepar may be required to subdue inflam- 
mation. 

(130) 



FRACTURE OF NASAL BONES. 131 



FRACTURE OF THE NASAL BONES. 

Although the nose is the most prominent feature of the face, 
its elastic tip and bony surroundings (forehead, chin, and cheek- 
bones) render its bony walls quite secure. If struck very hard, 
however, these usual safeguards may prove insufficient. 

Symptoms. — The symptoms are disfigurement, haemor- 
rhage, ecchymosis, swelling, emphysema, and abscess formation. 
Disfigurement is usually due to the depression of the nose, but 
may depend upon the swelling and ecchymosis. The pain is 
not usually severe, unless there be much swelling or an abscess 
form. Haemorrhage is at times severe, but rarely so marked 
as to require special attention. Swelling may occasion difficult 
respiration and render the diagnosis doubtful. Emphysema 
frequently results when the mucous membrane is torn ; the 
air being forced into the deeper tissues while sneezing, blowing 
the nose, etc. It may greatly impair respiration, but is not 
dangerous to life. Abscess may result from laceration of tissue 
or impairment of circulation. The mucosa and cartilages are 
often damaged. 

Diagnosis. — The diagnosis is not always easy, and, as the 
examination is usually quite painful, it is often best to use a 
general anaesthetic for highly nervous patients. It is not always 
possible to give an opinion until the swelling has been somewhat 
reduced ; but the defect should be determined as early as pos- 
sible, for the bones unite so readily that they may become fixed 
before being replaced. By inserting a probe within the nose 
and placing a finger outside, alternate pressure will usually 
detect crepitus. This may often be discovered by simply mov- 
ing the nose from side to side ; but care must be exercised to 
exclude the occasional physiological crepitus of the cartilages. 

Prognosis. — The prognosis is good if the patient be seen 
early, the diagnosis made with certainty, and the fragments 
properly replaced ; otherwise great deformity may follow. 

Treatment. — The fragments are to be replaced by means of 



132 DISEASES OF THE NOSE AND THROAT. 

such apparatus as a small probe, metal catheter, or lead-pencil. 
With the aid of the fingers outside, the fragments are to be 
gently molded into position, where they will usually remain ; 
when the swelling is great, it may be necessary to reduce a part 
of it before the broken bones can be re-adjusted ; to this end, 
hot applications act best in the early stage. If the nose be very 
much crushed, it may be necessary to insert nasal plugs to 
retain the bones in position, or a pin to keep the parts upright. 
If the former be employed, hollow tubes are the best, although 
cotton or oakum pledgets may be fitted to the cavity ; in either 
case they should be carefully removed daily, and the passages 
thoroughly sprayed or syringed. The bones will sometimes 
remain in position at the end of two days, so that the plugs may 
be left out at the expiration of that time ; but it is better to 
replace them for five or six days. If a pin be required, it may 
be passed through the nose in such a manner as to support the 
bones ; it can be held in position by a rubber band passed over 
the point and head, and may be left in position six or seven 
days, removing the rubber band each day to relieve the press- 
ure. When abscesses form, they should be treated as stated 
under " Abscess of the Nose." Emphysema needs no especial 
care. 

Internal remedies are to be governed by the character of 
the symptoms ; aeon, and calend. are the most important. 

DEVIATION OF THE SEPTUM. 

This is one of the every-day conditions of the nose, and 
exists to a slight degree in most persons. Unless sufficient, 
however, to give rise to some annoyance, it should not be con- 
sidered worthy of treatment, for in the great majority of devia- 
tions the departure from nature is so slight that it never attracts 
the patient's attention. 

Etiology. — The causes of deflected septi have been variously 
described. They were formerly considered congenital in many 
instances, but the careful and extensive researches of Zucker- 



DEVIATION OF THE SEPTUM. 133 

kandl have partially disproved this idea. He says that before 
the age of seven years the bony and cartilaginous septum is 
always straight. This is not true of every case, however. Some 
attribute, as a cause of deviated septum, the habit of constantly 
using the handkerchief in the same hand when wiping or blow- 
ing the nose, thus always forcing the cartilage in the same direc- 
tion ; others, the habit of always lying with the same side of the 
face on the pillow. It is possible that a highly-arched or angu- 
lar hard palate has to do with this defect, as the septum, in 
attaining its growth, is obliged to bend to one side. Accident, 
either the result of a blow or a fall, is the most frequent cause of 
deflections. In many cases the septum grows more rapidly than 
the space which it occupies ; especially is this true of its carti- 
laginous portion, where most deviations exist ; thus it must bend 
upon itself and form either a curve or an angle ; in such a case, 
one nasal canal is enlarged at the expense of the other. 

Variations. — Where a double curve is formed, one passage 
may be narrowed in front, the other behind. If the S-shaped 
curve occupy a vertical position, the concavities and convexities 
running antero-posteriorly instead of vertically, both passages 
may be encroached upon anteriorly, posteriorly, or both, except at 
the posterior fourth of the septum, where there is often hyper- 
trophy, but, perhaps, never deviation. The septal deviation may 
be in the form of a sharp bend on one side, with a corresponding 
concave V on the other; or the ledge may extend in either a ver- 
tical or a horizontal direction. The septum inclines to the left 
side more frequently than to the right, be the cause what it may. 

Symptoms. — The symptoms are chiefly those of obstruction. 
Deformity is unusual. There is generally a concomitant nasal 
catarrh, due to hindrance to the anterior escape of the dis- 
charges. When the projection presses against the tissues of the 
opposing wall, irritation, reflex symptoms, erosion, ulceration, 
or even frequent epistaxis and pressure atrophy may follow. 

It is difficult, without careful examination, to determine the 
exact condition present. It may resemble a polypus, a thick- 



134 DISEASES OF THE NOSE AND THROAT. 

ened septum, perichondritis, abscess, haematoma, or a new 
growth. Deviation may be distinguished from a new growth 
or septal thickening by the corresponding concavity on the op- 
posite side of the septum, and from abscess, haematoma, or peri- 
chondritis, by the elasticity and bilateral nature of the enlarge- 
ment in these disorders. When the deflection has existed for a 
long time, hypertrophies are not unusual; so that both sides may 
be too prominent. 

Treatment. — The treatment is to be varied according to the 
form and amount of the defect. If very slight, the frequent 
daily pressure of the finger against the most prominent part 
may do some good, but cases which apply for treatment are 
rarely mild enough for such means. The various tents (sponge, 
laminaria, gelosin, and tupola) or Waldenburg's pneumatic 
douche maybe of service, but Jurasz's spoons 
(splints), which are made separable from 
Adams' forceps, of which they form a part, 
are best in cases where there is not a great 
redundancy of septum. Independent splints 
fig. 49.-boswokth's or clamps, of various patterns, are also used. 
Pure, soft-rubber intubation-tubes (Good- 
willie) are of use in mild cases, and after operations, in some of 
the more severe forms. Adams' straight forceps have gained a 
reputation in straightening bent septi,but recently other and more 
individualizing methods have been instituted. Originally cir- 
cular or oval pieces were punched out of the cartilaginous septum 
and the wound allowed to heal, leaving a smooth-edged per- 
foration. This, however, sometimes caused much annoyance, 
owing to occasional passive haemorrhages from the edges of the 
opening and to the accumulation of scabs and crusts about it. 
Steele's forceps and their numerous modifications were designed 
to overcome these defects. They are made with stellate and 
other shaped attachments for the purpose of breaking the con- 
tinuity of the cartilaginous (more rarely the bony) septum, after 
which a pair of Adams' smooth blades are used to crush or 




DEVIATION" OF THE SEPTUM. 



135 



force the parts into position. Plugging is not often required, 
but, when demanded, the formerly obstructed passage is filled 
with an ivory or hard-rubber plug or hollow tube, or packed 
with glycerin- or vaselin- coated cotton, lint, or oakum. This 
should be removed each day, the nose sprayed with perman- 
ganate of potassium or peroxide of hydrogen, and the dilator 
replaced until healing is complete. 




fT.A./ABNALL CO. />H/LA. 

Fig. 50.— Adams' Foeceps. 

Sajous ("Diseases of the Nose and Throat") makes a 
linear, antero-posterior incision through the most prominent 
portion of the convexity ; the index finger is then introduced, 
and the fragments forced into position by the overlapping of the 
cut edges. They are held in this position for some days by the 
use of oakum, daily changed until union is firm, which occu-' 
pies a period of about ten or twelve days. John B. Roberts 
holds the overlapped fragments in position by pins passed 




Fig. 51.— Steele's .Skptum-Forceps. 



through the nose and septum. No after-treatment is required ; 
when union is complete the pins are removed. 

Ingals has recommended an oblique incision from above 
downward and forward, through the mucous membrane cover- 
ing the greatest convexity. The membrane is then carefully 
dissected from the underlying cartilage, and a triangular piece 
of the deviation removed ; the base of the triangle should be 



136 DISEASES OF THE NOSE AND THROAT. 

directed downward. In removing the cartilage, care must be 
exercised that the mucous membrane of the healthy side be not 
perforated. The cut edges of the membrane are to be united 
by sutures. Oakum is used as in the other operations. 

In one case, in which a deflected cartilage was so long as 
to project from the tip of the nose, causing much annoyance by 
obstruction and disfigurement, I divided the mucous membrane 
covering the sharp, projecting edge, and dissected it from the 
redundant cartilage, which was then removed with scissors ; the 
incision was united with sutures. 

Atrophy of the septum narium is so often a part of the 
same process in other portions of the nasal labyrinths that it 
need not be dealt with here, although it is sometimes independent 
of other atrophic changes ; it is then chiefly confined to the 
cartilaginous portion. 

CONGENITAL MALFORMATIONS OF THE NOSE. 

If the trifling deflections and the retrousse nose be ex- 
empted, congenital malformations are rather infrequent. They 
vary in degree from complete absence of the nasal feature to the 
mildest form of internal defect ; of the former, one case alone 
has been reported. Fissures of the organ, whereby its upper 
surface is partially or completely open, so that the interiors of 
the fossae can be seen from above, are exceedingly rare ; cases 
in which the septum is perforated or altogether absent are more 
frequent ; occasionally the floor of the nose is cleft (cleft palate) ; 
or there may be the so-called "double-nose," which consists of 
a bifid septum, sometimes so complete that a probe can be 
passed through the opening from one end of the septum to the 
other. The posterior nasal opening may be entirely closed, 
either by bony, cartilaginous, or membranous structure (rather 
rare), or the anterior passages may be similarly affected ; of the 
latter, three cases have been recorded, — one by Delstanche and 
two by Jarvis. One or more of the turbinateds or other bones 
of the nose may be absent ; there may be adhesions between 



CONGENITAL MALFORMATIONS OF THE NOSE. 137 

the various portions of the nasal fossae of an osseous, cartilagi- 
nous, or fibrous nature, whereby the passage is partially 
obstructed ; or one nasal canal may be smaller than the other. 

The causes are the same as those which give rise to 
congenital defects in other portions of the body. 

Symptoms. — The symptoms depend upon the position, 
amount, and form of the defect. If the nose be absent, de- 
formity, anosmia, and mouth-breathing will exist ; with fissure 
the chief symptom is disfigurement with greater exposure ; a 
perforated or absent septum need not occasion any annoyance, 
but the bridge of the nose may sink ; if the hard palate be 
cleft, defective speech will be the chief annoyance ; when the 
anterior or posterior nares are closed, nasal breathing will be 
impossible ; absence of the turbinateds may not be noticed by 
the patient ; non-development of other bones may give rise to 
deformity ; adhesions, or synechia, may interfere with easy 
respiration and impair the voice and sense of smell ; when one 
passage is smaller than the other, the function of the smaller 
will naturally be interfered with ; when the septum is bifid, 
few, if any, symptoms may arise, but the partition may encroach 
upon the normal calibre of the canals and impair respiration. 

Treatment. — The treatment of absent nose is purely 
mechanical, and consists of plastic operations ; the same is true 
of clefts. An absent or perforated septum can scarcely be 
restored ; a cleft in the hard palate requires palato-plastic 
operations or plates; occlusion of the nares requires immediate' 
operation, in order to permit free nasal respiration, so essential 
to the newborn babe. Membranous or cartilaginous obstruc- 
tions may be overcome by the curved, guarded knife, although 
the galvano-cautery is usually to be preferred. Bony obstruc- 
tions require the use of a chisel, saw, electric motor, or dental- 
engine drill. Synechia which interfere with breathing or affect 
the voice require division with knife, scissors, galvano-cautery, 
saw, chisel, drill, gouge, or bone-forceps. 



CHAPTER XL 

Diseases of the Accessory Cavities. 

The antra of Highmore are those usually affected. Their 
diseases arise by extension from the nasal canals ; from stenosis 
of the duct due to hypertrophic rhinitis, nasal polypi, or trau- 
matism ; injury ; projection of the teeth (especially carious) 




Fig. 52.— Transverse Vertical Section through Orbits : Looking Backward. 
(From a photograph.) 



Posterior ethmoid eel 

Superior meatu 

Middle meatu 

Antrum of Highmor 

Inferior 




Key to Fig. 52. 



Orbit 

Superior turbinated 

Anterior ethmoid cells 

Middle turbinated 

Inferior turbinated 

Septum 



into the cavity ; caries of the alveolar processes ; the presence 
of tumors ; or division of the infra-orbital nerve. 

The changes which occur in antral disease are similar to 
those of catarrhal processes elsewhere ; but, as the disease 
progresses, the cavity mav become filled with a mucous, muco- 
(138) 



DISEASES OF THE ACCESSORY CAVITIES. 139 

purulent, or purulent accumulation, or new growths. Softening, 
caries, or necrosis of the bone may occur, or abscess form. 

Symptoms. — The symptoms are: pain in the superior max- 
illa, usually severe and throbbing, lancinating or dull, and 
worse when leaning forward; swelling and tenderness may 
appear over the affected region. The pain often extends to the 
teeth, or may originate in them, if they be the prime cause of 
the trouble, when there will be associated earache and much 
redness and sponginess of the gums. In some cases the pain 
involves the orbital region, and from pressure the optic nerve 
may be affected; if neglected, this may result in blindness. 
The eye is occasionally forced upward and inward. The 
swelling of the antral region may be extensive, and, as the 
bone yields, the enlargement become quite doughy, even fluctu- 
ating. If pus form (empyema), it may find an exit through 
the natural opening into the middle meatus, giving rise to a 
unilateral discharge of offensive, yellow pus, usually when the 
head is turned to the opposite side ; the teeth may loosen and 
fall out, giving exit to the pus through their sockets ; or the 
abscess may burst through the bony walls, alveolus, cheek, or 
orbit. When the nasal pus is carefully wiped away, a change 
of position will usually cause its re-appearance. 

Diagnosis. — In doubtful cases, where the symptoms are 
not characteristic, M. B,. Brown (JV. T. Med. Jour., July 19, 
1890) thoroughly cocainizes the nasal cavity and forces peroxide 
of hydrogen into the antrum with the aid of a long hypodermic 
cannula, bent at a quarter of an inch from its end ; this " is passed 
into the hiatus semilunaris, and a solution of peroxide of hydro- 
gen (1 part to 12 parts of water) is injected into the antrum. 
If pus be present, it is driven out, and fills the nose as a white 
foam. That the solution has entered the antrum will be made 
evident by the patient complaining of slight pain at the roots 
of the teeth and a sense of fullness in the cheek." Link sug- 
gests percussion of the hard palate to determine the condition 
of the antrum. 



140 



DISEASES OF THE NOSE AND THROAT. 



Voltolini introduced a method of examination which some- 
times aids in the diagnosis of antral diseases. The patient is 
placed in a darkened room, when a tongue-depressor, furnished 
with a small incandescent lamp, is introduced into the mouth ; 
the lips are then closed, when the antral region, if normal, will 

appear slightly less illu- 
minated than the sur- 
rounding bone ; but, if 
the cavity be the seat 
of tumors or opaque ac- 
cumulations, it will not 
be so bright. In all cases 
the sides should be compared. Cystic 
cases will be well illuminated, and 
where there exist marked pathologi- 
cal changes in the nasal cavities this 
method of examination is practically 
valueless. Latent antral diseases are, 
thus, frequently detected. 

When a collection of mucus 
occurs (hydrops antri), a similar set 
of symptoms presents itself, but the 
bone is never softened, as in the 
preceding condition. If the space 
be partially filled with mucus or pus, 
the rest of the cavity containing air, 
the patient will notice a swashing 
sound when the head is shaken. The 
tumors usually found in the antri are 
polypi, which occasion pain, swelling, and protrusion. Phleg- 
monous inflammation sometimes attacks the maxillary sinuses, 
the result of erysipelas, diphtheria, croupous rhinitis, or injury. 
Prognosis. — The prognosis is usually good if relief be 
afforded before much destruction of tissue, optic-nerve pressure, 
or blood-poison has occurred. Otherwise one or more teeth 




Fig. 53. — Bleyer's Tongue- 
Depressor and Incandescent 
Lamp. 



DISEASES OF THE ACCESSORY CAVITIES. 141 

may be lost, the face disfigured, the eye protruded, or vision 
destroyed. Death may result from blood-poison or from exten- 
sion of the disease to neighboring cavities. 

Treatment. — The treatment should be medicinal and 
mechanical. In the case of abscess, etc., if the pus cannot 
find an exit through the natural opening, an attempt may be 
made to pass a curved probe through this canal, — an exceed- 
ingly difficult and often impossible procedure. When the 
attempt is successful, the fluid may be drained off, although 
it may still become necessary to make an opening into the 
chamber, usually through the space left after the extraction 
of the first or second molar tooth. If the extraction fail to 
give exit to the pus, a probe or director should be pushed from 
below upward, toward the inner canthus ; but in some cases it 
is impossible, without drilling the bone, to enter the antrum 
through this partial opening. A gold or silver drainage-tube 
should be fitted, and, to prevent the entrance of particles of food, 
a plug adjusted ; this can be removed for cleansing purposes. 
Vent is thus given to the accumulated fluid. Mickulicz 
recently revived the operation of opening through the inferior 
meatus, using a bent knife. M. R. Brown proposes a new and 
apparently good procedure, the advantages of which appear to 
be better drainage, the retention of the tooth, and less danger 
that foreign substances (food) will enter the cavity. An opening 
is made " through the upper part of, or immediately above, the 
alveolus." Cocaine is used, and an incision made or a small 
piece cut out "just below the gingivo-labial fold, between the 
upper portions of the roots of the second bicuspid and first 
molar teeth. A drill, preferably driven by an electric motor, is 
entered, at the point of incision, into the soft tissues and directed 
upward, inward, and slightly backward, forming an angle of 
about forty-five degrees with the plane of the alveolus." 

After the maxillary sinus has been opened it is usually 
necessary to syringe the cavity frequently with a warm solu- 
tion of permanganate of potassium, carbolic acid, or peroxide 



142 DISEASES OF THE NOSE AND THROAT. 

of hydrogen. This should be repeated, by the patient, two or 
three times a day. Often the liquid forced through the new 
opening will find an exit into the nose. When pus has ceased 
to escape, the outer end of the drainage-tube may be perma- 
nently filled with a gold or other plug, in order to prevent the 
continuous and annoying discharge of normal mucus. 

When necessary to remove tumors, an incision may be 
made into the cheek over the antral prominence, the periosteum 
pushed to one side, and the bone trephined. 

Therapeutics. 

Arnica. — If there be symptoms of pyaemia, R. T. Cooper 
(" Diseases of the Ear ") advises this medicine, and adds : 
" Arnica seems to exert an almost specific effect upon septic 
poisoning." Von Grauvogl considers it a pyaemic prophylactic. 

Puis. — Orange-colored discharge from the nostril, especially 
the right, in antral abscess. 

Compare aeon., bell., china, hepar, kali iod., and silica. 

Disease of the frontal sinuses usually appears as a result 
of catarrhal conditions accompanying nasal affections ; but it 
may originate in the frontal cells, or be due to syphilis or injury. 
(See Fig. 54.) 

Symptoms. — The symptoms are sensitiveness to pressure ; 
pain, usually very severe, in the frontal region; supra-orbital 
neuralgia; defective memory; and impaired thought. If abscess 
form, the symptoms are most distressing, — pain is excessive, 
diplopia occurs, and the eye is often dislocated and protruded ; 
fever, malaise, and prostration appear. 

Sapejko {An. cV Oculistique) says: "Displacement of the 
eye outward and downward in young persons, downward and 
outward in adults, with almost normal mobility of the eye, 
means ectasis of the frontal sinus of that side." 

The abscess may discharge into the nose through the nat- 
ural canal, it may project the bone forward and require incision 



DISEASES OF THE ACCESSORY CAVITIES. 



143 



from without, or it may find an exit at the angle of the orbit or 
into the brain. If a fistula exist at the anterior or superior 
border of the orbit, with pulsation of pus or muco-pus, there 
need be little doubt of its connection with the frontal sinus. 




Fig. 54.— Vertico-antero-posterior Section. Septum Removed, During Section, 
Revealing Left Nasal Region. (From a photograph.) 



When the abscess empties through the temporarily closed infun- 
dibulum, there will be a profuse flow of pus into the nose, fol- 
lowed by immediate improvement. In ordinary catarrhal con- 
ditions of the frontal sinuses, the symptoms are relieved by the 
free discharge of mucus from the cavities. If the outlet become 



144 DISEASES OF THE NOSE AND THROAT. 

permanently blocked, an accumulation of mucus will give rise 
to hydrops, and a purulent collection to empyema of the cav- 
ities. Sometimes new growths occur in the frontal cells, and, 
although osteomata are the most frequent, mucous polypi and 
cysts may form. All are accompanied by severe brow-pain and 
supra-orbital neuralgia. 

As the result of accident or syphilis, the bone covering 
may be partially destroyed, opening the cavity from the fore- 
head and giving rise to chronic suppuration. The cells are 
occasionally dilated on account of repeated mucous or purulent 
collections, resulting in many of the symptoms enumerated 
under abscess. As these swellings press backward against 
the brain, symptoms of brain-lesion may be present, but, owing 
to the gradual dilatation, the brain-recession may be so insidious 
as to avoid any such symptoms. Occasionally, hernia of the 
mucous lining occurs, so that, at each time the nose is vigor- 
ously blown, air enters and distends the sac. 

Treatment. — If there be temporary closure of the infun- 
dibulum, relief will usually follow internal medication directed 
chiefly to the nasal condition. Sang, can., hepar, kali mur., 
puis., etc., are often indicated. Applications of iodide of glycerin 
(10 grains to 1 ounce), menthol (2 per cent), or menthol and 
camphor (3 grains of each to 1 ounce of glycerin), made to 
the mucous membrane of the middle meatus near the hiatus ; 
or a small piece of absorbent cotton, thoroughly soaked in a 
4-per-cent solution of cocaine, carefully passed up over the 
anterior surface of the inferior turbinated, will usually give 
prompt, although sometimes transient, relief. 

Some have advised and even practiced passing a probe or 
style through the canal to the frontal sinus. As this is very 
difficult, and often impossible, it may become necessary to make 
an opening from without. The skin should be divided immedi- 
ately below the eyebrow, near the bridge of the nose, the peri- 
osteum pushed back, and the bone perforated with a small tre- 
phine or drill. Relief may follow perforation of the anterior 



DISEASES OF THE ACCESSORY CAVITIES. 145 

plate ; care should be exercised not to penetrate the cranial 
cavity. The opening made, it is advisable to attempt the 
passage of a probe through the infundibulum, or, failing in 
this, a small bistoury may be passed into it, after which the 
probe will follow, as in operations upon the lachrymal apparatus. 
This accomplished, a drainage-tube should be inserted into the 
naso-frontal passage and . the wound kept clean by syringing 
with antiseptic warm water. As deformity usually follows tre- 
phining, and as sepsis is apt to occur, the operation should not 
be undertaken, if milder means offer hope. When tumors are 
to be removed, it may be necessary to first trephine or chisel 
away the bone. Hernias may require some form of pressure 
appliance ; in one case reported, the removal of a piece of 
necrosed bone resulted in a "radical cure " of the hernia. When 
the tissues are emphysematous, a pressure bandage will afford 
relief. 

Following operations upon the frontal cavities, the same 
care is required as in other operations, and similar medicines 
may be indicated. 

The ethmoid cells are quite frequently involved in nasal 
catarrh, less frequently in abscess-formations. Where some of 
the individual cells have been fractured, emphysema may result 
while forcibly blowing the nose. Ethmoid disease develops 
from nasal catarrh, either acute or chronic ; polypi or other 
tumors ; and traumatism. 

Symptoms. — The symptoms are: severe pain in the lower 
frontal region and exophthalmos, if there be much thickening 
of the ethmoidal tissue ; if ethmoiditis exist, the septum may 
be greatly thickened, impairing nasal respiration. Pus may be 
seen issuing, from the posterior cells, near the junction of the 
middle and posterior thirds of the upper surface of the middle 
turbinated, and, from the anterior and middle cells, from beneath 
the middle turbinated, as in antral suppuration. Nasal neo- 
plasms, especially mucous polypi, sometimes have their origin in 



146 DISEASES OF THE NOSE AND THROAT. 

the ethmoid cells ; finally, the ethmoid may become ivory-like, 
from the existence of an osteoma. 

Prognosis. — The prognosis of the simple catarrhal affec- 
tion is usually good ; suppurative changes are difficult to cure, 
but are not dangerous to life, unless they extend to the cranial 
cavity. Ethmoiditis may result in polypoid growths or necrosis. 

Treatment. — The treatment consists in thorough cleanliness 
of the nasal cavity in the region of the ethmoid openings, and, 
in some cases, surgical interference, chiefly by snaring off the 
middle turbinated bone, and, if necessary, drilling or curetting 
into the cells. 

The sphenoid cells are, so far as known, very rarely dis- 
eased, but, as they are so situated as to render examination 
impossible and diagnosis extremely difficult, their diseased con- 
dition may be overlooked. This difficulty in diagnosis is aug- 
mented by the fact that nearly the same symptoms may arise 
from disease of the antrum ; and Rouge has recorded one case 
in which he diagnosed disease of the maxillary sinus, which, 
when opened, was found normal, but the sphenoid sinuses 
furnished a large collection of pus. Owing to the difficulty of 
normal drainage of these cells, the secretions do not flow off 
freely, so that mucous and purulent accumulations may some- 
times exist ; tumors are infrequent. Owing to the proximity 
of the brain, great danger is to be apprehended from any 
decided collection within the sphenoid cells, and sudden uni- 
lateral blindness may arise from involvement of the optic-nerve 
sheath. Fortunately, such accumulations usually find an exit 
by the natural opening before serious damage occurs. Opera- 
tions upon the cells are not only difficult, but very dangerous; 
although the sinus might be opened through the nose, or by 
means of a curved trocar passed back of the soft palate. As 
yet, however, such procedures are too dangerous to be recom- 
mended. Tumors of the sphenoid may occasion symptoms 
similar to the preceding, and, like purulent collections, may 



DISEASES OF THE ACCESSORY CAVITIES. 147 

enter the cranial cavity, causing cephalalgia, meningitis, cerebri- 
tis, hEemorrhage, and death. Epileptic seizures are possible. 

According to E. Beyer, of Gratz (Ann. Univ. Med. Sci., 
1889), wounds of the sphenoid bone may result "(1) in fissures 
of the superior wall of the sinus, continuous trickling of 
cerebro-spinal fluid ; (2) ruptures of a fragment of the body of 
the bone may wound the internal carotid to the inside of the 
cavernous sinus and cause pulsating exophthalmia ; (3) continu- 
ation of the fissure in the canal of the optic nerve will cause 
compression or rupture of the optic nerve, and, consequently, 
amaurosis ; (4) if the fissure extend to the oval or round fora- 
men, it will produce anaesthesia of the second and third branches 
of the trifacial, and a rupture or wound of other and cerebral 
nerves may present simultaneously." 

It should be noted that in all the cavities maggots and 
other parasites may accumulate and give rise to intense suffering. 
Virchow has demonstrated the occasional presence of a calcare- 
ous lining of the pneumatic cavities, which may extend to the 
mucous membrane of the nose through the various cell-outlets. 



PART II 



The Pharynx and its Diseases. 




Fig. 55.— Vertical Section through Basilar Process. 
(From a photograph.) 

Upper and posterior portions of skull and the spinal column removed. Posterior pharyngeal wall 
divided vertically and stitched aside, revealing the naso-pharyngo-laryngo-oesuphageal region; looking 
forward. 



CHAPTER XII. 

Anatomy and Physiology of the Palate and 
Pharynx. 

The palate is composed of an anterior (hard) and a pos- 
terior (soft) portion. The former is bounded anteriorly and lat- 
erally by the alveolar processes, posteriorly by the soft palate. 
The mucous covering is tightly adherent to the periosteum ; it 
has a median ridge and lateral corrugations, and is lined with 
squamous epithelium ; under it are numerous glands. The soft 
palate (velum pendulum palati) is attached to the posterior 
border of the hard palate, — with which it is continuous, — the 
lateral walls of the pharynx, the edges of the base of the 
tongue, and the nasal fossae. It is a movable, membranous 
curtain, the lower border of which is free, and, when relaxed, 
generally rests on the tongue, separating the mouth from the 
pharynx ; but, when elevated, the curtain is withdrawn, reveal- 
ing a new cavity, — the oro-pharynx. The soft palate is com- 
posed of layers of muscular fibres and aponeuroses; contains 
vessels, nerves, and glands, and is covered on both sides with 
mucous membrane. Like the hard palate, it has a median 
raphe on its oral surface, which marks the line of union 
between the two sides ; occasionally, however, this bond of 
union is incomplete, and a cleft results. This may appear both 
in the hard and soft palates ; as a result, there may be regurgi- 
tation of food, defective articulation, imperfect resonance, etc. 

Extending from the soft palate, on each side, are two folds 
of tissue. Each anterior mucous fold incloses the correspond- 
ing palato-glossus muscle, and is known as the anterior half- 
arch, or anterior pillar of the fauces ; it passes to the tongue 
and acts as a constrictor of the fauces. The posterior folds, 
half-arches, or pillars of the fauces, contain the palato-pharyngei 
muscles, which pass to the pharvnx. Between the anterior and 

(151) 



152 DISEASES OF THE NOSE AND THROAT. 

posterior arch of each side is one of the faucial tonsils, the 
tonsils of daily speech, which form the lateral boundaries of the 
fauces. The anterior boundary of the fauces is an imaginary 
plane drawn between the anterior pillars ; the posterior bound- 
ary is a similar plane drawn between the posterior pillars. The 
base of the tongue forms the lower boundary. 

The uvula partially divides the faucial space into the 
arcades. This little appendage is covered with mucous mem- 
brane, and is composed of connective tissue, glands, and the 
posterior extremities of the two azygos uvulae muscles, which 



Hard palate 



Posterior half-arch 
Anterior half-arch 



Tongue 



Fig. 56.— The Normal Palate and Pharynx. 

lie side by side in the median line of the soft palate. Their 
functions are to elevate the uvula and aid the palato-pharyngei 
muscles in separating the mouth and pharynx. The uvula 
seems to aid in swallowing, in tone production, and in directing 
the post-nasal glandular secretions to the lingual tonsil. 

In addition to the muscles considered, namely, the palato- 
glossi, palato-pharyngei, and azygos uvulae, there are two other 
pairs of palatine muscles, — the levator palati, which serve to 
raise the soft palate, and the tensor palati, the action of which 
is indicated. These various muscles aid both in deglutition and 
in vocalization, while the levator palati have another function, — 




ANATOMY AND PHYSIOLOGY OF PALATE AND PHARYNX. 153 

that of aiding in opening the mouths of the Eustachian tubes, 
thus permitting aeration of the middle ears. Therefore, these 
muscles have much for which to be accountable, as they are 
instrumental in many cases of deafness. 

The faucial tonsils, or amygdala?, are oval glands, the 
size and shape of a hazel-nut. In health they should rarely be 
seen, unless the anterior pillar be pushed aside ; yet they vary 
much in size, form, and color within normal limits. Each gland 
is imbedded in the faucial, peritonsillar tissue, and inclosed in 
a capsule of connective tissue. On the free surface are from 
eight to eighteen openings, the entrances to the crypts (ton- 
sillar lacunae, or follicular glands). In addition to these, the 
tonsils contain " single-layer cavities, each of which includes 
several follicular folds and procures their common discharge at 
the periphery. The crypts of largest size and greatest depth 
are filled more or less with a yellowish substance composed of 
fat-molecules, loosened pavement epithelium, lymph-corpuscles, 
small molecular granules, and cholesterin crystals." (Bryson 
Delavan.) They contain no mucous glands. Their functions 
seem to be, as suggested by Kingston Fox (Jour. Anatomy and 
Physiology, 1886), that of absorbing the superabundant saliva. 
They may absorb septic germs as well. As, however, these 
organs secrete a clear, viscid liquid, there can be little doubt 
that a part of their duty is to lubricate the food, thus aiding its 
passage through, the faucial canal, pharynx, and oesophagus. It 
is generally believed that the tonsils, in common with other 
ductless glands, modify the blood elements and aid in the for- 
mation of the white corpuscles. Killian (Morphol. Jahrbuch, 
Bd. xiv) thinks the contained leucocytes have the power to 
destroy micro-organisms. It may be said, however, that the 
exact physiology of the normal faucial tonsils is still open for 
investigation. 

In the vault of the pharynx is an aggregation of follicular 
glands, known as the pharyngeal, third, or Luschlca's tonsil. 
Its anatomical structure is similar to that of the faucial tonsils. 



154 



DISEASES OF THE NOSE AND THROAT. 



Its physiological function is said to be that of lubricating the 
parts directly below, of absorbing waste nasal and lachrymal 
secretions while the body is recumbent, and of aiding blood for- 
mation. It is a reddish mass, and projects somewhat from the 
level of the surrounding mucous membrane. Until recently a 
bursa (pharyngeal bursa) was believed to have an anatomical 
existence in the centre of the pharyngeal tonsil. It is a fissure, 
presumably the remains of a foetal fissure, in the centre of 



ial cavity 
Right posterior nari» 



Basilar process 

Left middle turbinated 

Left inferior turbinated' 

Soft palate 

Mouth 

Pharyngeal wall, stitched back 



Laryngeal vestibul 
Arytenoid covering' 



Entrance to tEsophagu 
Posterior wall of oesophagus. 




Nasal septum 

Uvula 

Posterior faucial pillar 

Tonsil 

Tongue 

Epiglottis 



Ary-epiglottic fold 
Pyriform sinui 



Common carotid 



Fig. 57.— Key to Fig. 55. 



which is a small opening. Ganghofner says the so-called bursa 
pharyngea is a more or less deep depression or cavity. The 
opening of this depression is sometimes quite small, and, doubt- 
less, retention cysts of considerable size occur, owing to the 
inflammatory narrowing or closure of this opening. Besides 
the pharyngeal tonsil, the naso-pharynx contains numerous 
isolated follicular and conglomerate glands. 

The lingual, or fourth tonsil, situated at the base of the 



ANATOMY AND PHYSIOLOGY OF PALATE AND PHARYNX. 155 

tongue, directly in front of the epiglottis, seems to have uses in 
the economy similar to the other tonsils. It receives much of 
its fluid for absorption from the tip of the uvula. All of the 
tonsils are analogous to Peyer's patches. 

The throat, pharynx, or pharyngeal space is that cavity 
which extends from the base of the skull above to the lower, 
posterior edge of the cricoid cartilage below, where it ends in the 
oesophagus. It is from four to five inches long, quite elastic, and 
capable of expansion and contraction. It is largest above and 
smallest at its lower end. It is freely movable in all directions. 
Posteriorly, the pharynx is attached to the bodies of the first 
four cervical vertebrae ; laterally, it is in relation with the large 
vessels and nerves of the neck ; anteriorly, it has three exten- 
sive openings, — one above, into the nose ; a second near the 
centre, into the mouth ; and a third near its lower portion, into 
the larynx. (See Figs. 55, 57, and 58.) 

It is customary to divide the pharynx into three parts, — an 
upper, naso-pharynx, which extends from the vault to the level 
of the base of the uvula ; a middle, oro-pharynx, from the base 
of the uvula to the base of the tongue ; and an inferior, laryngo- 
pharynx, from the base of the tongue to the beginning of the 
oesophagus. 

The naso- or respiratory pharynx is bounded in front by 
the posterior portion of the nasal space, the septum, turbinateds, 
and posterior surface of the soft palate ; posteriorly, it is limited 
by the tissues covering the vertebral column ; laterally, by the 
mouths of the Eustachian tubes (sometimes congenitally 
occluded) and Rosenmuller's fossse (pharyngeal recesses). The 
oro-pharynx is bounded by the uvula, fauces, and base of the 
tongue, in front ; posteriorly, it has the same limitation as the 
naso-pharynx ; laterally, it is confined by the muscles of the 
sides of the pharynx. This is the channel for air and food, 
and forms the upper part of the so-called alimentary pharynx, 
the lower portion of which is the laryngo-pharynx. This 
latter division is bounded posteriorly as the others, anteriorly 



156 



DISEASES OF THE NOSE AND THROAT. 




Fig. 58.— Antero-postero-vertical, Section, Revealing Naso-pharyngo-laryn- 
GEAii Region. Compare Frontispiece. (From a photograph.) 



ANATOMY AND PHYSIOLOGY OF PALATE AND PHARYNX. 157 



by the larynx, and laterally by the same class of structures as 
furnish boundary for the oro-pharynx. 

In front and back of the mouths of the Eustachian tubes 
are two prominent folds of tissue, — the Eustachian lips. Back 
of each posterior lip is one of the fossae of Rosenmiiller ; these 
contain both mucous glands and adenoid tissue. At the lower 
end of the naso-pharynx is a fold of tissue, composed of mucous 
membrane, muscles, and glands, which stretches directly across 
the posterior pharyngeal wall at this point. This is known as 
the plica salpingo-pharyngea ; it assists in the closure of the 



Cranial cavity 








Anterior ethmoid cells . 


"\ J|i3R 




-Frontal sinuses 


Middle ethmoid cells ^_^ 


^\^^J 




Nasal vestibule 


Posterior ethmoid cells^. 

Sphenoid cells 

Superior meatus 4? 

Basilar process. — | 
Eustachian orifice-^-"! 


'%#/£» 


flM 


./^.Inferior turbinated 
____ — .Middle turbinated 
|k_-,Superior turbinated 
^g^Middle meatus 
Mw*Inferior meatus 
S|r~ Junction of hard and soft palates 


Kosenmiiller's fossa^s 


wWm$ 




gg/PTongue 


Uvula — | 




^^"""Epiglottis 


Laryngo-pharynx^ — \ 


% Afll^ihit 




Vallecular region 


Ventricle of larynx—-"""^ 






^^" Ventricular band 


Cricoid cartilage"^"^ 


S^lk 




s. ■ Vocal band 


Pharyngo-oesophageal junction 






Thyroid cartilage 
Trachea 




Key to Fig. 58. 





respiratory pharynx during deglutition. It moves downward 
and inward during phonation and deglutition, shutting off the 
superior from the middle pharynx. Its action is best seen in 
those who have cleft palate. 

The oro-pharynx needs no further consideration. 

The anterior portion of the laryngo-pharynx opens into 
the larynx and the lower into the oesophagus. Anteriorly, it is 
bounded by the epiglottis and the base of the tongue ; the pyri- 
form sinuses (Fig. 55) are at the anterior lateral portions, being 
the spaces between the thyroid cartilage and the vestibule of 
the larynx. Between the base of the tongue and the epiglottis 



158 DISEASES OF THE NOSE AND THROAT. 

are the vallecula?, into which food and other foreign substances 
are apt to fall. 

The entire pharynx is lined with mucous membrane con- 
tinuous with that of the nose and ears above, the mouth in 
front, and the larynx and oesophagus below. The naso- 
pharyngeal membrane is lined with columnar ciliated epithelium, 
the rest of the pharynx with the squamous, pavement, form. 
The mucous membrane is freely supplied with glands, blood- 
vessels, lymphatics, and nerves. 

The glands imbedded in it are of two kinds, — racemose 
and follicular. The former (acinous, or racemose) are found 
chiefly in the naso-pharynx, less abundantly in the oro-pharynx, 
and sparingly in the laryngo-pharynx. The posterior portion 
of the uvula and the posterior superior surface of the soft palate 
are freely studded with them. The follicular glands are found 
in all portions of the pharynx. According to Kolliker, an 
agglomeration of these glands is found in the posterior wall of 
the oro-pharynx, extending from the mouth of one Eustachian 
tube to that of the other. The lymphatics form a dense net- 
work, and empty into the glands at the angles of the jaws and 
at the sides of the hyoid bone and larynx. The glands at the 
angles of the jaws communicate with the tonsils ; hence their 
proneness to enlarge when these organs are diseased. 

The posterior portion of the pharynx, as well as the greater 
part of the lateral walls, is lined with a strong fibrous tissue 
attached to the anterior surface of the vertebral column, with 
which it is in relation by means of retro-pharyngeal cellular 
tissue. To this fibrous tissue are attached the constrictor and 
other muscles. 

The arteries of the pharynx are the superior and ascending 
palatine, the tonsillar, the ascending pharyngeal, the terminal 
branches of the internal maxillary and vidian, and the 
pharyngea suprema. Occasionally, the vertebral artery is seen 
pulsating in front of the bodies of the vertebras. The superior 
and ascending palatine arteries go to the palate and the tonsillar 



ANATOMY AND PHYSIOLOGY OF PALATE AND PHARYNX. 159 

to the tonsils, lateral walls of the pharynx, and root of the 
tongue. The veins form two plexuses. 

The sensory nerves spring chiefly from the trigeminus, and 
participate in the functions of taste, secretion, and reflex muscu- 
lar control. Meckel's ganglion supplies some of the tissues, while 
the gustatory portions of this region receive their nerve-supply 
from the glosso-pharyngeal. Most of the secretory branches 
arise from the chorda tympani. The motor nerves arise from the 
third division of the fifth, the facial, and the spinal accessory. 

The muscles of the pharynx are quite numerous, the most 
important of which are the stylo-pharyngei, which elevate the 
pharynx for the reception of food from the mouth, and the three 
constrictors — the superior, middle, and inferior — which, in turn, 
contract upon food and force it from above downward. They 
arise from the sphenoid and palatine bones, from the hyoid bone 
and stylo-hyoid ligament, and from the sides of the cricoid and 
thyroid cartilages, respectively. They are all inserted into the 
fibrous aponeurosis of the pharynx posteriorly. 

Ruedinger has shown that there exists a special muscular 
stratum between the glands of the palate and the muscular 
tissue, by which, in conjunction with the various muscles, the 
glands are compressed. 

The oesophagus extends from the lower end of the pharynx, 
back of the trachea, to the stomach ; its upper extremity is seen 
(by reflected light) as a transverse shadow-line, as it is only 
opened by the entrance or exit of gases, fluids, or solids. It 
can, however, be dilated with the cesophagoscope, when its 
interior may be viewed. 



CHAPTER XIII. 

Examination of the Pharynx — Pharyngoscopy. 

The illumination and position of the patient are practically 
the same for pharyngeal as for posterior rhinoscopic examina- 
tion. During the inspection of the fauces and oro-pharynx, the 
patient can usually depress the tongue and elevate the soft 
palate and uvula sufficiently to permit a fair view ; where this 
cannot be done, however, some form of tongue-depressor will 
be a necessity. These depressors vary from a smooth stick, 
probe, or spoon-handle to instruments especially constructed for 
the purpose. The simplest and most useful depressor is the 
back of a rhinoscopic or laryngoscopic mirror. It is light, 
easily handled, and, when once in the mouth, can be used to 
examine the naso-pharynx, the laryngo-pharynx, or the larynx. 
This is a great desideratum, especially with children and very 
nervous adults. 

In selecting a regular tongue-depressor, it is well to see 
that it is aseptic ; that is, with no roughness or transverse serra- 
tions for the lodgment of dirt, germs, or disease products. 
Smooth, slightly concave, hard-rubber, celluloid, or plated 
metal is the nicest surface to place in contact with the tongue, 
although fenestrated, wire tongue-depressors answer every pur- 
pose. After contact with the mouth or nose, every instrument 
should be thoroughly washed in a disinfecting solution and 
wiped before further use. A cherry-colored solution of per- 
manganate of potassium seems least objectionable and sufficiently 
germ-destroying for all save such diseases as diphtheria and 
syphilis. For the latter special instruments should be used, 
and in no case should a throat instrument once used near a 
secondary syphilitic ulceration or mucous patch be used for 
non-syphilitic cases. 

When depressing the tongue, the patient should be re- 
(160) 



EXAMINATION OF THE PHARYNX PHARYNGOSCOPY. 



161 



quested to open his mouth without moving his tongue from its 
position. The depressor should be introduced well toward the 
back of the tongue, and gentle, but firm, pressure exerted 
downward and forward ; at first the tongue may push against 
the instrument and rise above its former level, but a moment's 
gentle pressure will serve to depress it. In the majority of sub- 
jects, however, no force will be required, as the tongue will 
at once yield ; on the other hand, the patient may be so sensi- 
tive as not to permit the entrance of any instrument within the 
mouth. It may then become necessary to institute gentle but 
careful practice ; this failing, the patient may be requested to 
hold pieces of ice or iced water in his mouth, or (rarely) the 




-Cohen's Hard-Rubber 
Tongue-Depressor. 




.— Hingeb Metal Tongue- 
Depressor. 



mouth and throat may be sprayed with a 2- to 4-per-cent solu- 
tion of cocaine. When examining an exceedingly refractory 
child, who will not open his mouth, the nostrils should be 
tightly closed for a few moments, when the lips (and generally 
the mouth) must of necessity open. As children will some- 
times bite, it is important, before introducing the finger into the 
mouth for the purpose of examination, to protect it by a guard 
(Fig. 18, page 25), made of either metal or leather. 

In making an examination of the throat, it is advisable to 
look at the lips and inside of the cheeks for the presence of 
mucous patches, ulcers, new growths, anaemia, etc. ; the gums 
for vascular, scorbutic, phthisical, or lupoid changes ; the teeth 



162 DISEASES OF THE NOSE AND THROAT. 

for hereditary syphilis, overcrowding, necrosis, and capability to 
properly masticate ; the tongue as a general guide and index ; 
the hard palate, especially with reference to anaemia, hyperemia, 
syphilitic and parasitic affections ; the soft palate as to color, 
diphtheritic and other deposits, parasites, syphilitic gummata and 
ulcers, phthisis, mobility, clefts, etc. ; the uvula as to retraction, 
relaxation, new growths, malformation, etc. ; the half-arches as 
to color, adhesion to the tonsils, new growths, ulceration, etc. ; 
and the tonsils with reference to size, ulceration, inflammation, 
abscess, new growths, etc. 

The oro-pharynx should be rather pink, smooth, moist, and 
lustrous ; but to these there are some physiological exceptions : 
thus, there may be slight irregularity, or one side of the pharynx 
may be more prominent than the other, owing to correspond- 
ingly greater development of the bodies of the vertebras. 

Inspection of the naso-pharynx has been detailed under 
" Posterior Rhinoscopy." The laryngo-pharynx and base of 
the tongue require, for their examination, the laryngoscopic 
mirror and, occasionally, the finger. 



CHAPTER XIV. 

Pharyngeal Diseases. 



ACUTE CATARRHAL PHARYNGITIS. 

Although the pharynx receives the force of the inflamma- 
tion, the uvula, tonsils, fauces, and even the soft palate rarely 
escape. As the inflammation descends, the larynx often suffers, 
the extent of its involvement depending upon the severity of the 
attack, the already weakened condition of the organ, and the 
force of the exciting causes. In the first place, the vasomotor 
nerves receive a shock from which they do not promptly recover, 
the capillaries are dilated, the blood-current slowed, leucocytes 
escape, and the mucous cells wander, giving rise to an inflamma- 
tory process. The follicles of the pharynx and tonsils partici- 
pate, although not so exclusively or extensively as in true 
follicular pharyngitis or tonsillitis. 

While the force of the attack is expended upon the 
mucous membrane, the deeper tissues do not escape ; as a result, 
there is often marked infiltration and an exudation of a cheesy 
material from the tonsils, or even from the surface of the 
pharynx. In addition, there is sometimes transudation of the 
serous properties of the blood, giving rise to veritable cedema. 

Etiology. — The causes of this affection are numerous, the 
chief of which is the contraction of " cold " from draughts of 
air, either warm or cold ; from profound chilling, the result of 
exposure ; from too sudden changes of temperature, want of 
proper food or clothing, wet feet, alcoholism, mechanical irri- 
tants, tobacco, numerous irritant drugs, etc. The pharynx may 
offer the least resistance, and thus become inflamed, unless 
promptly treated. The person attacked may have been singing 
or speaking and gone into the cold air before he was thoroughly 
cooled, or lie may have neglected his customary, but pernicious, 

(163) 



164 DISEASES OF THE NOSE AND THROAT. 

habit of wrapping or muffling the neck. Spring and autumn 
(the changeable seasons) furnish a large proportion of such 
attacks. Children suffer more than adults, women more than 
men. The scrofulous and syphilitic diatheses act unfavorably 
in youth. In adults, rheumatism, gout, poor or too highly 
seasoned food, improper clothing, bad hygiene, vitiated atmos- 
phere, sedentary habits, tobacco, and alcohol each has its share 
of the burden in producing acute pharyngitis. 

Symptoms. — The attack may be ushered in by a chill or, 
more usually, by a feeling of malaise and chilliness, rise of tem- 
perature, headache, and pain in various joints ; the neck and 
back frequently ache ; the cervical glands swell ; and pain, sore- 
ness, and sticking are often constant on one or both sides, 
aggravated, however, by deglutition. During the latter func- 
tion, pain may shoot up into the ears through the Eustachian 
tubes. Air inhaled may seem cold or hot, and the throat is 
usually dry and stiff. Thirst is often considerable and attended 
by frequent efforts at empty swallowing, usually more painful 
than deglutition of large mouthfuls of food or liquid, which 
generally relieve by their moisture. The voice is thick ; there 
may be repeated efforts to clear the throat of a viscid, trans- 
parent, grayish mucus ; and the hearing is frequently affected 
from involvement of the Eustachian mucous membrane. Should 
the larynx be involved, hoarseness, irritating cough, and a full- 
ness or painful sensation in that organ usually result. The neck 
is often stiff and the laryngeal region tender. 

Early inspection of the pharynx reveals a congested and 
often a dry, glazed surface ; later, it becomes thickened, fre- 
quently irregularly roughened from swelling of the follicles, and 
partially covered with a glossy, gluey, or brownish secretion, 
through which enlarged vessels are often seen. This appear- 
ance is sometimes mistaken for mucous patches. The fauces 
participate in the inflammatory process ; the uvula is generally 
elongated, thickened, and sometimes cedematous; the soft palate 
congested; and the tonsils somewhat enlarged and at times 



ACUTE CATARRHAL PHARYNGITIS. 165 

studded, especially on their posterior portions, with spots of 
whitish deposit, the secretion from inflamed follicles. This is 
easily removed, is not followed by any bleeding, and does not 
leave an abraded surface, as in diphtheria. If both tonsils and 
uvula be swelled, the breathing is rendered somewhat difficult, 
especially in children. At first the expectoration is slight and 
accompanied by painful efforts to dislodge, but later it becomes 
profuse, muco-purulent, purulent, or bloody, and, usually, 
readily removed. Should the larynx be implicated, its lining 
membrane will be congested or even well inflamed. As 
the disease subsides the cervical glands, if enlarged, decrease in 
size, tension, and tenderness, and the pain on deglutition grows 
less : but the symptoms may pass away suddenly. 

Prognosis. — As the disorder is usually a mild one, prompt 
recovery is the rule ; but occasionally the process of resolution 
is incomplete, leaving the throat subject to chronic catarrh or 
to another attack at the next unusual exposure. The duration 
of the attack is usually from two to eight, rarely ten to fourteen, 
days, the average being about four, provided prompt treatment 
be instituted. As a rule, the attack can be aborted. One of 
the worst features is the implication of the larynx, which 
usually augments the duration of the inflammation. 

Treatment. — The treatment is usually clearly defined and 
the remedy well indicated. The patient can often be made more 
comfortable by the use of carefully directed local measures, first 
of which is the use of a spray of a fluid petroleum prepara- 
tion : pieces of ice, held in the mouth, are grateful to many 
patients, while to others warm water is more soothing. When 
there is oedema, tannic-acid applications, 15 grains to the ounce 
of glycerin or fluid albolene, are of value. Gargles are of con- 
siderable utility if the procedure be carried out according to the 
method of Hagen, but, as usually practiced, the fluid used 
rarely passes the limits of the posterior pillars. Hagen advises 
that the mouth be a little more than half filled with the gargle, 
the head bent back, the mouth widely opened, and a complete 



166 DISEASES OF THE NOSE AND THROAT. 

movement of deglutition performed, with the mouth open ; if 
necessary, a wedge may be placed between the teeth. Little, 
if any, of the fluid will reach the stomach. The air is then 
allowed to gurgle through the liquid as long as possible, when 
the tip. of the tongue is to be placed against the upper incisors 
and the head thrown quickly forward, followed by the ejection 
of the fluid through the nose. Oily sprays and nebulas are both 
soothing and beneficial. 

The food should be bland and usually soft, and, if the 
attack be severe, chiefly liquid. Hygienic care is important, 




The American Nebulizer. 



and will be found sufficiently considered under " Chronic 
Pharyngitis." 

Therapeutics. 

Ammon. mur. — Sore throat, with a viscid phlegm so tough 
that it cannot be hawked up. Throat swelled externally and 
internally. Sensation of rawness in the naso-pharynx and 
pharynx. Hoarseness, with burning in the larynx. 

Amygd. pers. — " Angina faucium, with soreness and ach- 
ing pains, but without any characteristics calling for other 
remedies. — Jeans." (Korndcerfer.) 

Apis. — Throat feels constricted, as if a foreign body were 
in it ; burning, stinging pains ; swelling or cedema of the uvula 



THERAPEUTICS OF ACUTE CATARRHAL PHARYNGITIS. 167 

and fauces ; tonsils red and swelled ; pharynx shiny and puffed ; 
difficult deglutition and respiration. 

Bell. — Bright-red throat ; pains (right side the worse) ex- 
tend up the Eustachian tubes ; painful or impossible deglutition, 
yet constant effort to swallow ; fluid escapes through the nose. 
Anterior cervical glands swelled and tender, even before the 
throat feels sore. 

Caps. — Elongated and cedematous uvula ; dusky-red fauces 
and pharynx ; burning soreness. 

Dolichos. — " Pain, as from a splinter, near the right tonsil ; 
worse when swallowing. This pain like a splinter reminds us 
of hepar, silic, carbo veg., and nitr. ac." (Dr. A. Korndcerfer, 
Hahnemannian Monthly, June, 1890.) 

Fer. phos. — Throat, palate, fauces, and tonsils dry, red, 
burning, and painful. High fever. 

Guaiac. — " In the ordinary forms of pharyngitis, such as so 
frequently develop after cold, it is nearly a specific remedy, much 
superior to bell, and other medicines which are generally pre- 
scribed." (W. C. Goodno, Hahnemannian Monthly, February, 
1891.) 

Iodide of silver. — " Swelling in the submaxillary-gland 
region ; stiff neck ; difficult deglutition ; has to force food 
down ; viscid, gray, jelly-like mucus, easily expectorated early 
in the morning. Throat raw and sore ; when yawning, painful 
tension in the fauces. Constriction in the throat, impeding 
deglutition ; ulcer in the throat, with swelling of the glands of 
the neck (chlor. gold)." (E. M. Hale, Trans. Amer. Ins. 
Horn., 1889.) 

Kali bi. — Mucus thick, tough, stringy, viscid; pharyngeal 
fullness, rawness, and burning; shooting pains through the 
tonsils and up the Eustachian tubes ; membrane red or pale 
and relaxed. 

Kali mur. — Although purely clinical, I have come to re- 
gard the following symptom as an integral part of the kali-mur. 
picture : A dry, stiff, burning sensation, confined to the naso- 



168 DISEASES OF THE NOSE AND THROAT. 

pharynx ; gaping, and, to a less extent, deglutition, produces a 
painful feeling, which might be likened to the crumpling of a 
varnished throat. 

Lach. — The subjective symptoms are often much worse 
than the appearance would indicate ; as a rule, little change is 
noted at first (many times verified). The throat feels con- 
stricted ; constant desire to swallow, although difficult and 
painful ; throat dry, shining, dusky red, mottled. Tenacious 
mucus ; pain extending up to the ears (left worse). External 
tenderness. 

Merc. iod. ruber. — The following (clinical) symptoms have 
repeatedly disappeared during the administration of the 3 x in 
1-grain doses every four hours. A white, follicular point with 
a red areola on the left posterior pillar; sensation of a sore 
spot, with or without the foregoing ; sticking on swallowing 
saliva, but scarcely noticeable when swallowing food or liquid. 
This condition is associated with pharyngitis, and is especially 
noticed in those who have been in attendance upon diphtheritic 
patients. 

Merc. sol. — The tongue is thickly coated, white, and takes 
the imprint of the teeth ; free flow of saliva ; metallic odor and 
taste ; pharynx dull-red and swelled ; lancinating pains extend 
to the ears during deglutition ; anterior cervical glands swelled; 
and pain in the muscles of the neck. 

Natr. ars. — Thickening of the pharyngeal lining; varicose 
veins ; oedema. Dissecting-room sore throat, with intense dry- 
ness, smarting, and burning in the pharynx, 1 have repeatedly 
seen cured by natr. ars. 

Phyto. " has proved of considerable value in acute pharyn- 
gitis, especially in the early stages and when the attack is in 
a rheumatic or syphilitic subject. The symptoms that call 
for its administration are : General debility, nausea, and severe 
headache ; stiffness and soreness of the muscles ; rheumatic 
and neuralgic pains in various parts of the body ; swelling of 
the lymphatic and other glands, and irritation of the eyes and 



SUBACUTE CATARRHAL PHARYNGITIS. 169 

nose. The tongue is rough and sore on the edges, very red at 
the tip, with severe pain at the root ; the throat feels full, dry, 
rough, and smarting ; the soft palate and tonsils are swollen ; 
the mucous membrane of the throat is dark-red, sometimes 
ulcerated, or there is a dark pseudomembrane upon it; a 
thick, tenacious saliva fills the fauces, causing: hawking; and 
cough ; swallowing brings a feeling of a lump in the throat, and 
severe pain that shoots along the Eustachian tubes through the 
ears." (Winslow, " The Human Ear.") In addition, it may 
be said, the throat feels rough, hot, dry, and burning ; the lining 
membrane may be of a dark, bluish red. 

Sang. can. — Throat feels as if scalded by hot fluids or as 
though it would crack ; dry, burning not relieved by drinking ; 
pharynx very red. 

SUBACUTE CATARRHAL PHARYNGITIS. 

Etiology. — Subacute pharyngitis has for its causes similar 
conditions to those referred to in treating of the acute form. 
Pathologically, the changes are slight, consisting of mild hyper- 
emia and blood-stasis, with exceedingly mild inflammation. 

Symptoms. — The symptoms calling attention to this affec- 
tion are aching, dryness, burning, fullness in the throat, and 
pain or discomfort from " empty " swallowing. Swelling and 
tenderness of the cervical glands are rather frequent. These 
symptoms are usually worse in the morning, and often pass off 
after eating, to return, however, in a short time, or perhaps not 
till the following day. The affection may last for some days, 
but its usual duration is short, frequently not longer than a few 
hours. Inspection rarely reveals more than a slight hyperemia 
of the pharynx or tonsils. 

Prognosis. — The prognosis is good, although subacute 
pharyngitis may act as the starting-point of the acute disorder. 

Treatment. — Merc. sol. stands as almost the panacea for 
such a condition. A salt-water gargle and cosmolin spray or 
nebula are the most useful adjuvants. Gastric disorders should 



170 DISEASES OF THE NOSE AND THROAT. 

be regulated and the hygienic principles noted under " Chronic 
Pharyngitis " considered. 

ANGINA ULCEROSA HEMORRHAGIC PHARYNGITIS CACHECTIC 

ANGINA. 

This affection was originally described by Morell Mac- 
kenzie and E. Wagner. There appear slightly elevated white 
or yellowish-white spots, either diffuse or circumscribed. The 
outer epithelial layers are lost ; the deeper are cedematous, 
purulent, or hemorrhagic ; ulcers may finally result. The con- 
dition occurs in impoverished persons, septic states, dissection 
wounds, etc. The chief remedies are ars. alb. and iod., fer. 
phos., lach., phos., and sang. can. 

CHRONIC CATARRHAL PHARYNGITIS. 

Etiology. — The causes of the affection are: incomplete 
resolution of some of the preceding forms of pharyngitis, 
chronic nasal catarrh, exposure to irritating vapors or dust, 
unaccustomed exposure to bad weather, insufficient clothing, 
damp feet, highly seasoned or hot food, gastro-intestinal disor- 
ders, use of the voice in the open or dust-laden air, an improper 
use of the voice in singing or speaking, etc. It has been 
denied by some that alcohol and tobacco take an active part 
either in the production or perpetuation of this affection, but 
their deleterious influence is now well established upon the tes- 
timony of hundreds of trustworthy physicians and patients. If 
any further elucidation be desired, it may be obtained from 
Mr. Lennox Browne's " Voice Use and Stimulants." Mouth- 
breathing, as a cause of chronic pharyngitis, must not be over- 
looked (see " Physiology of the Nose "). 

As a result of these influences, the mucous and submucous 
tissues are thickened (hypertrophied) ; the glands enlarge, be- 
come overactive, and throw off a superabundance of a more or 
less thick, discolored secretion, which, when exposed to the air, 
parts with its moisture and dries on the mucous surface. The 



CHRONIC CATARRHAL PHARYNGITIS. 171 

chronic change is aggravated with each subsequent acute ex- 
acerbation. As the disease progresses, the membrane thus 
thickened presents an irregularly roughened appearance, with 
here and there atrophic patches. Ulceration is never present 
in purely catarrhal pharyngitis, but atrophy may occur late in 
the affection and lead to a true atrophic pharyngitis. Heryng 
first described a non-catarrhal ulcerative pharyngitis of short- 
duration, which leaves no scar. Its favorite location is on the 
lateral Avails. 

Symptoms. — The symptoms of chronic pharyngitis, al- 
though varied, are quite characteristic. They chiefly consist 
of dryness, fullness, and burning in the throat ; and the accumu- 
lation of scanty or profuse mucus of a thick, thin, viscid, ropy, 
tenacious, or lumpy nature, and which may be white, green, 
yellow, brown, or bloody. The patient usually clears the throat 
frequently, and at times makes fruitless efforts to expectorate ; 
deglutition may be frequent, painful, and difficult ; the voice is 
often husky, weak, and uncontrollable, and its use fatiguing 
and followed by hoarseness ; the singing compass is generally 
curtailed and the tones are frequently flat. Irritation of the 
superior laryngeal nerve may be accountable for the loss of the 
higher tones and, to some extent, the fatigue and hoarseness. 
As complications of chronic catarrhal pharyngitis, none are so 
distressing, so disabling, or so constant as chronic laryngitis. 
One of the accompaniments of this disease is irritation and 
cough, arising either from the enlarged glands or vessels, or 
from the presence of an elongated uvula. The voice is fre- 
quently interrupted by a sudden dropping of discharge into the 
larynx or the dislodgment of secretion from some part of that 
organ, into which it has gradually trickled from above. Hear- 
ing is often impaired, even lost, either from mucous accumula- 
tion in the Eustachian orifices or an extension of the catarrhal 
process to the middle ear. 

Should the pharyngitis result from indigestion, the symp- 
toms will be, prominently, a sense of burning and smarting ; the 



172 DISEASES OF THE NOSE AND THROAT. 

tongue generally more or less coated; the glands somewhat 
hypertrophied ; the mucous membrane rather dull, with some 
enlarged vessels coursing over its uneven surface: not unusually, 
the tonsils partake of the hypertrophic process. If of syphilitic 
origin, without any well-defined characteristics, the membrane 
may be purplish ; if of hepatic origin, the appearance will be 
much as in the gastric variety. When scrofula has its share in 
the production of chronic pharyngitis, the cervical and other 
glands may be involved and the patient present the peculiar 
scrofulous appearances, the special features of which will be 
described under " Scrofula of the Pharynx." The same may be 
said of the phthisical and follicular forms. 

The appearances presented in the uncomplicated catarrhal 
variety are thickening and irregular congestion of the mucous 
membrane, which is often coated with discolored discharge. 
The pharynx may be somewhat unevenly hypertrophied, or 
spots of atrophy may appear, and enlarged vessels be seen 
within the membrane. The soft palate and pillars are often 
congested and thickened, the uvula relaxed and enlarged, and 
the tonsils increased in size. 

Although rarely described, Lateral Chronic Pharyngitis is 
not an infrequent condition. This form of pharyngitis seems to 
be due to imperfect methods of voice production and to the 
inordinate use and abuse of the voice. 

In this variety the tissues back of the posterior pillars are 
hypertrophied, deeply congested, and especially prominent when 
the patient makes an effort to depress the tongue and elevate 
the soft palate. The posterior pharyngeal wall is usually pale, 
indicating a partial atrophy of its tissues, thus pointing to a 
long-existing process. It is, therefore, natural to infer that the 
tissues in the posterior wall are less able to withstand the 
atrophic process than are those in the lateral walls. Although 
I have carefully noted the progress of these cases, I have never 
seen a true lateral atrophy follow the hypertrophic process. 
Partial deafness is frequently associated with lateral hypertrophy, 



CHRONIC CATARRHAL PHARYNGITIS. 173 

owing to extension of the process to the Eustachian tubes ; and 
varicose veins often appear in the glosso-epiglottic space and on 
the base of the tongue ; these may require treatment with the 
galvano-cautery point, although hamamelis, internally, has often 
acted satisfactorily. Under the influence of iodine 3 x or fer. 
iod. 3 x internally, and the iodide of glycerin locally, the lateral 
tissues often assume a fairly normal appearance. 

Prognosis. — It may readily be inferred that the prognosis 
of chronic pharyngitis is not good after the pathological change 
is great, as it is difficult to restore even a fair amount of the 
normal character of the mucous membrane. On the other 
hand, some very severe cases yield so gracefully to treatment 
that one is agreeably surprised at the recuperative forces of 
nature, when properly aided by judicious treatment. It is 
unwise, however, to promise a cure even in mild cases ; yet, 



E.A.YARNALLPHHA. 



Fig. 62.— Author's Pharyngeal and Post-Nasal Applicator. 

relief can safely be promised in all, provided the patient faith- 
fully obey instructions and will remain under treatment a few 
months. 

Treatment. — From a review of the causes that may give 
rise to chronic catarrhal pharyngitis, it seems but proper to lay 
down this wholesome axiom : Remove the causes and treat the 
symptoms that first appeared, leaving those not easily included 
with the primary symptoms for later consideration. As many 
of the patients are dyspeptics of the most settled form, the gas- 
tric, hepatic, and rectal regions are to be looked to with especial 
diligence. 

In the treatment with adjuvants, the first and most impor- 
tant point is to practically cleanse the affected area. This may 
be done either with the spray or cotton carrier, after which the 
adjuvant should be applied by the same means. Where prac- 



174 DISEASES OF THE NOSE AND THROAT. 

ticable, the remedies indicated internally should be used on the 
pharynx. Aqueous hydr. may be used in its crude form ; kali 
bi. or kali permang. in a 1-per-cent aqueous solution ; soda 
bicarb. 5 percent; and eucalyptus 10 per cent. Tannic acid, 
gr. x; chloride of zinc, gr. v; and iodine, gr. x, to glycerin, Sj, 
are good as occasional applications when the previous remedies 
fail. Dr. C. Bartlett recommends pyoktanin (blue), J gramme 
to 2 drachms of water. Ten minims of this are added to 1 
ounce of pure glycerin, and applied with brush, etc., especially 
in hypersecretion. {Hahnemannian Monthly, June, 1891.) 

Wet or damp feet should be properly dried after an expo- 
sure, and, in order that the occurrence of habitually damp feet 
may be prevented, it is well for the patient to have two or three 
pairs of shoes, so that they may be worn on alternate days. 
Muffling the neck is to be avoided, as it tends to weaken the 
throat. For the purpose of improving the circulation in this 
region and of strengthening the tissues, it is well to bathe the 
neck and upper chest in cold salt water every morning, following 
this application by a moderate rubbing with an ordinary towel 
and vigorous friction with a crash or Turkish towel or flesh- 
gloves, until the parts become quite pink. If this be started in 
mild weather, any one will soon become accustomed to it ; but 
if it be instituted in cold weather, the water should be slightly 
warm at first, followed successively by cooler applications, until 
it can be used as it flows from the faucet. 

Therapeutics. 

Aesch. — As noted by Dr. T. F. Allen, this remedy well 
suits pharyngitis beginning in the posterior nares, and asso- 
ciated with dryness, burning, and scraping ; the mucous secre- 
tion may drop into the larynx and cause choking. Backache, 
constipation, haemorrhoids. 

Alumina. — Throat feels very dry, especially on waking ; 
sensation of a splinter ; frequent post-nasal droppings ; thick 
and tough mucus ; nasal catarrh ; fullness in Eustachian tubes, 
which momentarily open with a snap on deglutition. Hoarseness. 



THERAPEUTICS OF CHRONIC CATARRHAL PHARYNGITIS. 175 

Argent, met. — Expectoration of lumps of pure mucus, like 
boiled starch. 

Calc. phos. — Sensation of dryness and burning in naso- 
pharynx during empty swallowing or when swallowing first 
mouthful of food or fluid, not after. Worse if one have not 
spoken or swallowed for a short time ; fullness in naso-pharynx, 
either imaginary or due to the presence of mucus mixed with 
blood ; pure, partly-coagulated blood ; or yellowish-white and 
thick discharge. Adenoid vegetations furnish the pathological 
basis for these symptoms in many cases, and, as pointed out by 
that close observer, Dr. R. T. Cooper, this remedy is almost a 
specific for these growths. When swallowing saliva, the calc- 
phos. patient sometimes feels as though the uvula had been 
swallowed and had adhered to the posterior wall of the pharynx, 
where it would choke him ; only relieved by a repetition of 
deglutition. 

Cepa. — Sensation of water dropping into pharynx. Nasal 
secretion watery and acrid ; lachrymation bland ; pharynx feels 
rough and raw, with a tickling in the larynx, producing cough. 

Elaps. — In speaking of otorrhcea, Dr. H. C. Houghton says 
(" Clinical Otology ") it is " indicated in the chronic suppura- 
tive form of disease, complicated with naso-pharyngeal catarrh ; 
the posterior wall of the pharynx covered with crusts, or mucous 
membrane fissured ; nasal mucous membrane in same condition ; 
external [auditory] meatus full of offensive, yellowish-green dis- 
charge, which stains the linen green ; membrana tympani usu- 
ally perforated. Subjective symptoms : Congestive, lancinating, 
frontal and occipital headache, aggravated by motion and stoop- 
ing. This remedy is of great value in the naso-pharyngeal 
catarrh which complicates aural disease in children. The pa- 
tients are compelled to sleep with the mouth open, on account 
of the obstruction of the nose; hence the term snuffles, used by 
mothers and nurses." (See also " Chronic Nasal Catarrh.") 

Fagopyrum. — Mucus dries in crusts in the naso-pharynx; 
rawness, dryness, and dry crusts ; intense itching and burning ; 
follicular pharynx ; aggravation from the least exposure. 



176 DISEASES OF THE NOSE AND THROAT. 

Hamam., natr. ars., phytolac, puis., and vespa. — Varicose 
veins in the pharynx. 

Hydr. can. — Tenacious, yellow, or white expectoration from 
the posterior nares ; rawness of the pharynx and faucial region ; 
sticky, stringy mncns, which runs down from naso-pharynx in 
ropes, difficult to remove with instruments. Hydrastis has an 
especial affinity for the posterior nares and Eustachian tubes, and 
is often associated with tinnitus aurium, depressed and opaque 
drum-membranes, and impaired hearing. The pharynx may be 
glazed, tense, or dry, with expulsion of tough, greenish masses. 

Kali bl. — Pharynx glossy, dark-red, or coppery. Mucus very 
stringy or ropy ; hoarseness in the evening. " Usually where 
hyperemia of the vault exists, with dryness and moderate 
secretion." (Malcolm Leal.) 

Under date of November 20, 1889, Dr. A. C. Peterson, of 
San Francisco, wrote : " I have seen many cases of hypertrophic 
forms of disease attacking the naso-pharynx, with marked 
increase in size of the pharyngeal tonsils, attended with symp- 
toms of ever-present constriction, fullness, and often with an 
acute susceptibility to extremes of temperature ; very hot or 
very cold food and drink causing extreme pain. In such con- 
ditions I have had excellent results from the application of 
absorbent cotton carrying a solution of kali bichromicum vary- 
ing in strength from a half-drachm of the drug to the ounce, up 
to a saturated solution, even. 

" In general hypertrophic pharyngitis, where the hyper- 
trophy is considerable and the redness pronounced, the kali solu- 
tion in a spray has been of signal service in restoring a natural 
condition of the part." 

Kali iod. — " Burning, scraping, roughness of the throat ; 
expectoration is greenish, stringy, and salty. Also in specific 
cases with throat symptoms after mercury." (C. F. Sterling, 
" Diseases of the Ear.") 

Kali mur. — Dr. Sterling, in speaking of this remedy in 
chronic tympanic catarrh, says : " It seems to lessen the secre- 



THERAPEUTICS OF CHRONIC CATARRHAL PHARYNGITIS. 177 

tion, clear out the accumulated mucus, and reduce the chronic 
swelling of the mucous membrane in the throat, tubes, and 
tympanum. The particular indications for its use are a palish, 
anaemic throat, more or less thickened conditions of the mucous 
membranes and membrana tympani, closure and stoppage of 
the Eustachian tubes, and adhesions of the drum-head." Thick, 
tenacious secretion; small, cheesy lumps; opaque, white, or 
yellowish-green crusts in the vault of the pharynx. 

Magnes. phos. — Hypertrophy of pharyngeal structures; 
choking often during deglutition ; spasmodic cough. 

Merc, dulcis. — Mucosa dark-red; pharynx and uvula thick, 
relaxed, and infiltrated; secretion thick, yellow, often with a 
dry, sore, raw, obstructed sensation extending up the Eustachian 
tubes. 

Merc. iod. rub. — Enlarged and indurated tonsils and cervi- 
cal glands ; tough, white, or green mucus collects, in hard 
lumps, in the naso-pharynx ; throat feels sore and scalded on 
waking, especially during empty swallowing ; throat dark-red; 
chronic follicular tonsillitis and lacunar, cheesy collections. 

Natr. mur. — Glazed appearance and dry, smarting sensa- 
tion, despite a frequent hawking up of thin, transparent mucus. 
Uvula elongated. Tobacco-users' sore throat. 

Nux vom. is an invaluable remedy in chronic pharyngitis; 
especially when prescribed upon the gastric indications and with 
a raw, sore, rough, scraped feeling in the throat ; loose cough, 
with thick, grayish expectoration, and a sensitiveness to pressure 
in the supra-sternal notch. 

Penthorum. — " Posterior nares raw as if denuded ; contin- 
ual feeling as though the posterior nares were moist." (IT. D. 
Champlin, Med. Advance, September, 1888.) 

Phytol. — Sensation of dryness, scraping, rawness, or of a 
ball of fire in the throat, and dryness aggravated by hot fluids. 
Constant desire to clear the throat ; swallowing produces severe 
pain in the ears on account of dryness. 

Wyethia. — Pricking, dry, burning sensation in posterior 



178 DISEASES OF THE NOSE AND THROAT. 

nares ; difficult deglutition, with dryness of the pharynx, often 
associated with the sensation of a lump in the naso-pharynx. 
Swelling of the lining of the pharynx and fauces. (I am 
chiefly indebted to Dr. F. M. Selfridge for my knowledge of 
this valuable drug.) 

ACUTE TRAUMATIC PHARYNGITIS. 

Etiology. — This, as its name implies, is an acute inflamma- 
tion of the pharynx and surrounding tissues, the result of injury, 
either from the introduction of foreign bodies, a thrust from 
some object, the inhalation of caustic vapor, or the deglutition 
of scalding water, ammonia, etc. The accident may result in 
the formation of oedema, emphysema, a slough, or an abscess. 

Symptoms. — The symptoms are not unlike those of acute 
catarrhal pharyngitis, but the sensation of sticking or of a 
foreign body is more marked. Should the inflammation ex- 
tend to the larynx, it is not unlikely that the voice will be lost 
and the breathing impaired ; necessitating astringent inhala- 
tions, scarification, intubation, or tracheotomy. If a large 
abscess or marked oedema of the pharynx occur, there will be 
more or less difficulty in respiration. The temperature often 
rises to 103° or 104° F. 

Prognosis. — If the pathological process be checked early, 
the prognosis is usually good ; but an abscess may form, im- 
portant tissue be destroyed, or blood-poison ensue. When the 
pharynx has been punctured with a blunt, rusty, or dirty 
instrument, retro-pharyngeal abscess may result. 

Treatment. — If a foreign body be present, it must be re- 
moved. If the pharynx be scalded or injured by caustics, the 
inflammatory reaction should be promptly combated with medi- 
cines and soothing, emollient applications or sprays. Calendula 
(20 per cent), peroxide of hydrogen (15 volume), or pyoktanin 
(1 to 100) should be frequently applied. It is necessary to 
neutralize the caustic or acid swallowed if it have entered the 
stomach or if some particles still remain in the pharynx or 



ACUTE FOLLICULAR PHARYNGITIS. 179 

oesophagus. A large abscess should be opened with great care, 
as noted under " Retro-pharyngeal Abscess " ; when near the 
surface, it may be evacuated by dissection from the skin surface. 
Aeon., calend., fer. phos., and staph, should usually be our 
main remedies. The complications call for the remedies noted 
after them. 

ACUTE FOLLICULAR PHARYNGITIS. 

Etiology. — The etiological factors are not different from 
those of acute catarrhal pharyngitis, with which this affection 
is closely allied ; but, while the inflammatory process in the 
former is generally distributed to the mucous membrane, tonsils, 
and follicles, in follicular pharyngitis the force of the patholog- 
ical change is expended on the follicles themselves, the sur- 
rounding tissues being but slightly involved. 

The process consists of a fibrinous overdistension of the 
follicles, which shows itself in the enlargement of a number or 
even a chain of these little glands. The vessels running up to 
the elevation early enlarge, and the mucous membrane sur- 
rounding the follicle inflames : a fibrinous product soon appears 
at the apex of the reddened prominence, and is expelled, so 
that the follicle generally returns to its normal condition in a 
few days. The fibrinous exudation is usually very tenacious 
and scant, though at times so profuse as to give the impression 
of a pseudomembrane not unlike that found in diphtheria ; 
upon careful inspection, however, it will be found in isolated 
points, and not in a continuous layer. In other instances the 
rupture of the follicle leads to ulceration, especially in debili- 
tated and dyspeptic persons or in those who are addicted to the 
use of alcoholics. 

Symptoms. — The affection is often ushered in with a chill 
and general aching of the neck, back, and legs ; the prostration 
is frequently pronounced; and the temperature elevated to 102° 
or 103° F. The subjective throat symptoms are acute pain, 
worse in the median line and on swallowing, and a sensation 
of splinters, constriction, and dryness in the throat. Expecto- 



180 DISEASES OF THE NOSE AND THROAT. 

ration is moderate, and of a glutinous, fibro-mucous character. 
The objective changes are often so slight that it is difficult to 
account for the severity of the pain and dryness ; for this reason 
acute follicular pharyngitis is often overlooked in a hasty 
examination. In some cases the glands are very small and the 
surrounding inflammation slight ; while in others the glands 
present quite large, red elevations, with decided involvement of 
the surrounding membrane. The follicular apices become 
lighter in color, after a day or two, and exude a cheesy, fibrin- 
ous material. It is not unusual to be able to insert a small 
probe into the crypt and give exit to the accumulated discharge. 
The enlarged follicles may occupy the upper part of the pharynx 
only, or reach to the oesophagus ; and although they are usually 
situated on the sides of the pharynx, near the posterior pillars, 
they may form in the median line, or extend from the vault of 
the pharynx in such a manner as to present a chain of enlarge- 
ments running from above downward. Examination of the 
external surface of the neck will generally demonstrate the 
presence of enlarged and tender glands. 

By attention to the preceding indications the diagnosis is 
usually very easily established. 

Prognosis. — The prognosis is generally good ; resolution 
occurs in a few days, often in forty-eight hours ; but, as with 
acute pharyngitis, there is a possibility of imperfect resolution 
and the establishment of a chronic follicular pharyngitis. 

Treatment. — Internal remedies are of chief importance, 
but, owing to the burning dryness, it is advisable to order a 
gargle of salt water ; a gargle or spray of glycerin (one tea- 
spoonful), alcohol (one-fourth teaspoonful), and water (four 
teaspoonfuls) ; a spray of a 5-per-cent albolene solution of 
eucalyptol ; or pure fluid albolene, fluid cosmolin, or benzoinol. 

Therapeutics. 
Alumina. — Throat dark-red, follicular, and relaxed. 
Caps. — Much burning and an enlarged chain running 
down the side of the pharynx, the left especially. 



CHRONIC FOLLICULAR PHARYNGITIS. 181 

Fer. phos. and kali mur. — In speaking of follicular pharyn- 
gitis, Dr. W. A. Dewey writes : " I am pretty sure I cure 
ulcerated sore throat more quickly with fer. phos. and kali mur. 
than I used to with mercury and kali bi. or bell. I always give 
these two remedies, and have come to look upon them as sure." 

Kali mur. — Where the post-nasal burning is the most promi- 
nent symptom; the inflammation and glandular enlargement are 
chiefly confined above the soft palate. 

Sang. nit. — One of the best remedies, clinically. Burning, 
stinging in the pharynx ; stringy, gluey discharge. 

Compare 8esch.,rhus tox., and wyethia. (See next subject.) 

CHRONIC FOLLICULAR PHARYNGITIS — CLERGYMAN'S SORE THROAT. 

Although this is usually merely a local expression of some 
other condition, it seems best to present the subject in a special 
division, as the symptoms are characteristic and distinct from all 
other forms of pharyngitis. 

Etiology. — The causes of chronic follicular pharyngitis are: 
rheumatism, gout, alcohol, tobacco, illy-ventilated rooms, irri- 
tating fumes, obstructive nasal catarrh, and imperfect subsi- 
dence of congestion of the mucous membrane and follicles. 
The last either as the result of inflammatory action or, more 
often, of congestion of a purely local nature, as when the blood 
is driven to the part by the over- or improper use of the vocal 
apparatus, known as the " throaty " method of voice-production. 

Pathology. — The blood-vessels, when overdistended and 
weakened by the intense pharyngeal contraction during throaty 
vocalization, do not return promptly to their normal calibre ; 
as a result, the pharyngeal follicles are forced into too great 
activity ; an over-amount of mucus is secreted and temporarily 
retained, which, if often repeated, leaves the follicles distended 
or even hypertrophied. In a short time the walls of the vessels 
become thickened, the fibrous elements increased, and the gland 
overfilled with the extra secretion, which cannot escape on ac- 
count of inflammatory thickening and narrowing of its punctum. 



182 DISEASES OF THE NOSE AND THROAT. 

Finally, this secretion becomes thick, cheesy, fibrous in nature 
and consistence, and is often expelled in round lumps, which, 
when broken, are very offensive. They are frequently ejected 
violently when coughing or clearing the throat. Ulceration 
sometimes occurs from long retention and pressure of these 
cheesy masses. If the congestion occur infrequently, and the 
parts return to their normal condition each time, hypertrophy 
may not follow. 

Although often called clergyman's sore-throat, it is not 
entirely, or even generally, confined to members of that profes- 
sion ; for singers, speakers, smokers, drinkers, dyspeptics, and 
even those who make no special use of the voice are some- 
times its victims. Congestion of other organs is often a coeval 
change ; this is particularly true of the pelvic viscera and liver. 

Symptoms. — In the early stages the patient usually makes 
no complaint, as there may be nothing more than a slight dryness 
or stiffness present, with frequent desire to swallow. Later, the 
symptoms become more pronounced, and cough and hoarseness 
supervene, from involvement of the larynx. This may follow 
the use of the voice during acute attacks of pharyngitis, when 
much fatigued bodily, or when the easy high limit of the voice 
has been transgressed. As a premonitory condition the stomach 
is often deranged, but, if it escape at first, it is usually affected 
later, owing to entrance of the discharges. These are occasion- 
ally frothy, dark-brown, or black, from admixture of dust, etc., 
although generally tenacious, the patient not infrequently gag- 
ging or even vomiting during efforts at dislodgment. 

Inspection of the pharynx reveals the presence of enlarged 
patches, which vary in size from small granules to grains of 
sago, or larger. The surface of the membrane is often con- 
gested, and enlarged veins course through it from follicle to 
follicle. The elevations may be pale, dark red, or almost 
purple, and sometimes yellow at their summits (obstructed 
follicles filled with fatty material). The enlarged follicles 
usually occupy the sides of the pharynx, or occur opposite the 



CHRONIC FOLLICULAR PHARYNGITIS. 183 

lower border of the soft palate. Sometimes there are only two 
or three of them, but usually they are quite numerous, even 
studding the entire surface of the pharynx ; the uvula may be 
almost covered with them. The enlarged vessels, at times, form 
true varix at the base of the tongue and greatly complicate the 
case. 

Prognosis. — The prognosis is favorable, for, while the 
affection is stubborn, it is not usually incurable. It may, how- 
ever, destroy the glands and adjacent tissues, giving rise to 
atrophic catarrh or true pharyngitis sicca; but usually some 
glands remain hypertrophied after others atrophy, thus pro- 
ducing an uneven surface. 

Treatment. — It is the almost universal teaching that the 
use of the singing voice be discontinued while the diseased con- 
dition is being treated ; it is my practice, however, — and experi- 
ence fully warrants its continuance, — to insist upon the patient 
continuing the use of the voice, but under the strict supervision 
of a competent vocal instructor. Without this aid treatment is 
incomplete. 

Remedies should be administered internally and locally. Of 
the latter, glycerin and iodide of glycerin prove most useful. 
If the symptoms call for the employment of either ammonia, 
argent, nit., cubebs, kali bi., sang, can., or sang, nit, the drug 
may be used locally, as well as internally, either as gargle, 
spray, insufflation, or pastille ; in the latter instance gelatin or 
sugar of malt should be used as a base. One of the most 
efficient gargles is : glycerin, 1 teaspoonful ; alcohol, J tea- 
spoonful ; water, 4 teaspoonfuls. Local remedies may be used 
by the patient once or twice daily, according to circumstances. 

Some have recommended the destruction of the enlarged 
follicles with cautery, galvano-cautery, or caustics ; others, that 
the blood-supply of the follicle be cut off by destruction of the 
afferent vessel with the galvano-cautery point. These destruct- 
ive agents often hasten the atrophic change, if, indeed, they be 
not the first step in its production ; they are, therefore, not to 



184 DISEASES OF THE NOSE AND THROAT. 

be compared with the milder measures, which frequently restore 

both the hypertropied follicle and the adjacent tissue to a fairly 

normal condition. 

Therapeutics. 

Aesch. — Dry, uncomfortable feeling, or constriction with 
raw, excoriated, pricking sensation ; frequent hawking of clear 
mucus ; pharynx and fauces relaxed, swelled, and dusky red. 
Hemorrhoidal patients. 

Ammon. bromat. — Follicular pharyngitis with chronic 
cough ; scanty, stringy, mucous expectoration (ammon. iod.). 
Pharynx looks mottled ; fauces dark-red and congested. 

Ars. iod. — Pharynx both follicular and hypertrophied, with 
burning, rawness, and soreness ; frequent hawking ; nasal dis- 
charge watery and often excoriating. Tinnitus aurium ; laryn- 
geal involvement ; general weakness ; threatened tuberculosis. 

Badiago, chemophil., kali bi. — Pellets of cheesy matter fly 
from the mouth during coughing and hawking. 

Calc. phos. — In young persons with glandular and tonsillar 
enlargements ; strumous and lymphatic individuals ; besides the 
enlarged follicles, there is some general pharyngeal hypertrophy. 
An intercurrent. 

Cinnabar, kali bi., sepia, and teucr. — Hardened clinkers are 
hawked from the posterior nares. Teucr., when very large and 
irregular ; cinnabar, if of a dirty-yellow color. 

Hepar. — Cough, muco-purulent discharge, and hoarseness 
with relaxed uvula, all of which are aggravated in changeable 
weather, especially in changes from warm to cool. 

Kali bi. presents a picture very closely resembling the affec- 
tion under consideration, in the dry, irritable state of the 
pharynx ; the scanty discharge, which is tough, stringy, sticky, 
and difficult to dislodge ; and in the discharge of little pellets. 

Kali brom. — Dr. John MeyhofFer says : " We have derived 
much satisfaction from its use in follicular pharyngitis when 
atony was the predominant feature of the morbid process, while 
iodine or iodide of potassium requires irritation as the leading 
symptom." 



THERAPEUTICS OF CHRONIC FOLLICULAR PHARYNGITIS. 185 

Kali mur. — Membrane between the enlarged follicles 
rather pale and thin ; discharge of white, tough mucus ; ade- 
noid vegetations. Catarrhal deafness ; throat deafness ; closure 
of the Eustachian tubes. If given for some time it lessens the 
tendency to acute attacks of both nasal and pharyngeal catarrh ; 
the same is true of Hydrastis, but in a higher degree. 

Lach. "has a state of venous congestion, a puffed look of the 
uvula, tonsils, and soft palate ; it has irritability of the throat, 
a constant desire to swallow, a feeling of a plug in the throat, 
and a tenderness of the larynx ; but there is not that deep- 
seated chronic inflammation of the glands of the pharynx that 
makes Kali Bichromicum, Mercurius Iodatus, and Hejjar /Sid- 
pliuris come tripping along to our memory. As the Iodide of 
Mercury bites deep down to the follicular disease of the 
pharynx, so should the Iodide of Sulphur penetrate to the 
inmost recesses of the gouty or scrofulous constitution." (E. B. 
Schuldham, " Chronic Sore Throat.") 

Nux vom. — The following observations are purely clinical, 
but I have so often verified them that I look upon them as charac- 
teristic. Atrophic, white patches, the size of a split pea, with a 
few enlarged follicles ; as soon as a tongue-depressor or mirror 
is passed beyond the lips the patient gags and retches, but 
especially for those who have, as a pharyngeal reflex, a laryn- 
geal tickling, augmented by tobacco-smoke ; persons with gas- 
tric disorders and constipation ; and those who are addicted to 
the use of alcohol and tobacco. 

Sang. nit. — Burning, soreness, rawness in the naso-pharynx 
and pharynx; discharge of thick, yellow, or even bloody mucus. 
This is my sheet-anchor in chronic follicular paryngitis, and is 
the remedy to use in the absence of clear indications for 
another. 

Wyethia. — Dryness, burning, constant desire to clear the 
throat; tendency to atrophy; pharynx dark-red, sensitive; feels 
swelled ; constant desire to swallow to relieve the dryness ; 
swallowing difficult. 



186 DISEASES OF THE NOSE AND THROAT. 

ATROPHIC PHARYNGITIS PHARYNGITIS SICCA. 

Etiology. — Pharyngeal atrophy is an occasional sequel to 
those affections which have just been considered. Further 
causes are atrophic rhinitis, post-nasal catarrh, adenoid vegeta- 
tions, hypertrophied tonsils, mouth-breathing, and senile changes. 
Atrophic pharyngitis is rarely occasioned by any of these con- 
ditions, however, without the long-continued accompaniment 
of chronic pharyngitis. 

In looking for an expression of the changes which give the 
disease its distinctive title, it will be noted that there is often 
atrophy of the glands, vessels, mucous membrane, or even of 
the muscles ; thus, the secretion is scanty or almost suppressed, 
the blood-supply diminished, and muscular tone lessened or 
lost. The pharynx becomes dry, glazed, very pale, and appears 
spacious ; the uvula and soft palate are often thinned. The 
deeper pharyngeal structures lose their elasticity and, owing to 
lack of nourishment, atrophy ; so that the bodies of the verte- 
bras may stand out in decided contrast to the smooth, rounded, 
velvety pharynx of health. Pulsating arteries and veins are 
occasionally seen in the posterior pharynx. 

It may be stated, in the way of explanation, that there is a 
net-work of veins, on the lateral and posterior pharyngeal walls, 
which empty into the jugular veins. This net-work is the termi- 
nal for numerous veins which come from the muscles and mucous 
membrane, and go to form the submucous venous net-work. 

Schech (" Diseases of the Mouth, Throat, and Nose ") 
calls attention to the frequent association of diabetes and 
Bright's disease with atrophic pharyngitis. 

Symptoms. — The first symptom that is apt to attract the 
patient's attention is the decided dryness and stiffness of the 
pharynx, especially during empty deglutition ; when swallowing 
food, the first mouthful may cause annoyance, but the throat 
soon becomes lubricated and the meal is finished in comfort ; at 
its conclusion there is a decided sense of relief. Owing to the 



ATROPHIC PHARYNGITIS — PHARYNGITIS SICCA. 187 

loss of muscular tone, the epiglottis often participates and 
remains partially erect ; on that account food often passes into 
the larynx and elicits reflex cough and spasm. This mishap is 
aided by the insensitive condition of the membrane lining the 
epiglottis and the upper part of the larynx. 

As stated, the pharynx is glazed in appearance ; at first, 
atrophy occurs at numerous points, but as these spread the pos- 
terior portion may present pale, vertical streaks, due to loss of 
the mucous and glandular tissues and the exposure of the 
underlying fibrous structure. Later, the entire pharynx may 
present a peculiar, white, sclerosed, glazed appearance. At 




Fig. 63.— Whitall, Tattjm & Co.'s Vaselin Atomizer. 

times small particles of adherent, tenacious, dry mucus appear 
upon the surface ; at others the greater part of the pharynx is 
covered, the discharge trickling from the posterior nares. 

Prognosis. — The natural inference would be that such a 
condition could not be much improved ; but this is not always 
true, especially in young subjects. When well advanced in 
years temporary improvement is all that need be anticipated. 

Treatment. — Treatment should be directed to the nose and 
naso-pharynx, as well as to the directly local and constitutional 
condition. The pharynx should be kept thoroughly cleansed 
with some slightly irritating solution for the purpose of exciting 
the atrophic tissue to greater activity. To this end Hydrastis 



188 DISEASES OF THE NOSE AND THROAT. 

canadensis goes a long way ; the muriate of ammonia, iodine, 
and chloride of zinc also prove efficient. These remedies are 
best applied in the second decimal dilution or trituration, with 
glycerin as a vehicle. In the absence of an atomizer, the 
preparation should be applied with the aid of a brush or cottoned 
probe. Galvanization and massage of the diseased structure have 
recently proved additions to the treatment of atrophic pharyngitis. 
The positive pole should be applied to the pharynx, the negative 
to the neck, preferably back of the sterno-cleido-mastoid muscles. 
" In atrophic catarrh my best results have been from ars. iod. 
3 x and a local use, after thorough cleansing, of thymol and 
olive-oil, 20 grains to the ounce." (E. L. Mann.) 

Therapeutics. 

Argent, nit. 2 x to 6 x has proved most efficient during the 
early atrophic stage. 

Ars. iod. is one of the first remedies to think of. 

Calc. iod. — Especially in rachitic and scrofulous patients. 

China. — Muscular relaxation, cough, dilated vessels. 

Kali bi. " has an affinity for the mucous membrane, and is 
occasionally needed in atrophic pharyngitis, complicated or not 
by nasal catarrh. The symptoms calling for its administration 
are : A yellowish-red or tawny color of the pharynx ; relaxa- 
tion of the palate, and oedema of the uvula ; shallow, grayish 
ulceration, showing no disposition to heal ; red, swollen, or 
ulcerated tonsils ; dryness and soreness of the posterior surface 
of the soft palate ; hawking of thick, tenacious mucus, difficult 
to dislodge ; and mucous rales in the Eustachian tube and ear." 
(Winslow, " The Human Ear.") 

For other remedies, see " Atrophic Rhinitis." 



CHAPTER XV. 

Acute Infectious Diseases. 



ERYSIPELAS OF THE PHARYNX. 

Erysipelas occasionally manifests itself in the pharynx 
after the skin is involved (usually severe), before the external 
redness appears (usually mild), or at the same time (moderately 
severe). Young adult females are more frequently attacked 
than males. 

Etiology. — The causes are the same as those which give 
rise to the external variety. Its course is a rapid one. Although 
usually epidemic, it may be sporadic. Extension from the ears, 
nose, and throat is by continuity of tissue. 

Pathology. — Pathologically, the changes are the same as 
when other parts are invaded by the disease, but ulceration and 
gangrene are more frequent in the pharynx. Some writers 
consider erysipelas of the pharynx and phlegmonous pharyn- 
gitis identical. 

As erysipelas of the pharynx is associated with the 
external eruption, its diagnosis is not difficult, after the appear- 
ance of the external rash ; but previous to this the greatest 
difficulty obtains. The one appearance most nearly pathogno- 
monic is a peculiar glazed red, which does not seem to occur in 
other forms of pharyngitis. 

Symptoms. — Before any other symptom manifests itself, the 
temperature usually rises to 103° or 104° F., and the frequency 
of the pulse and respiration is augmented in like proportion ; 
pain on deglutition, swelling of the cervical glands, and a 
burning, stinging stiffness in the affected part are among the 
early symptoms ; these may last two or more days before either 
the cutaneous or mucous erythema makes its appearance. Soon 
the bright, glazed redness occurs ; this may be the only observ- 

(189) 



190 DISEASES OF THE NOSE AND THROAT. 

able pharyngeal change, but, as a rule, the process goes on to 
the formation of phlyctenulae ; these may burst in a few hours 
and leave a whitish or yellowish spot, but they are usually 
replaced by bullae and vesicles, which sometimes become as 
large as ordinary grapes. The vesicles and bullae contain pus 
or serum, and bear a general resemblance to herpes of the 
pharynx. 

The two conditions described are those usually seen, 
although ulceration and gangrene may supervene, with the 
separation of superficial sphaceli. Even from this condition the 
patient may recover, although death usually results from col- 
lapse or a low typhoid state. (Edema is frequent, and the 
inflammatory area may extend over the entire pharynx, includ- 
ing the soft and hard palates, uvula, and tonsils ; it may pass 
downward to the larynx, or upward and involve the nasal cavi- 
ties, lachrymal canals, Eustachian tubes, and middle ears. When 
the patient recovers, the mucous membrane desquamates over 
the entire area affected. 

Prognosis. — The prognosis is grave, — much more so than 
in the purely cutaneous variety, — for deglutition and nutrition 
are impaired, and the ulcerative and gangrenous processes may 
result in great loss of tissue, haemorrhage, and septicaemia. 
When erysipelas attacks the larynx as well as the pharynx, it 
may produce fatal dyspnoea, the result of oedema. About 20 
per cent of the cases prove fatal under ordinary methods, but 
by careful homoeopathic treatment this fatality can be decreased. 

Treatment. — Internal remedies usually relieve, but the 
patient can generally be made much more comfortable by mild 
local measures ; in the severe forms the latter are demanded 
either for the purpose of disinfection or for aiding the separation 
of the sphacelus. The patient may suck pieces of ice to 
advantage ; a spray of carbonate of soda and water is soothing 
and cleansing; steam inhalations are valuable if gangrene 
appear ; and peroxide of hydrogen and permanganate of potas- 
sium are best as disinfectants. 



HOSPITAL SORE THROAT. 191 

Therapeutics. 

Apis. — (Edema of uvula ; fauces and pharynx violet-red ; 
stinging, burning pains, with a sensation of constriction ; ery- 
sipelas, beginning on tonsil and palate and extending to larynx. 

Anthracinum. — "Submucous tissue infiltrated, cedematous; 
erysipelas; cellular cynanche." (Hering.) 

Ars. — Extension from the skin ; tendency to attack the 
various internal organs ; intense burning in the pharynx ; great 
prostration ; marked oedema, even gangrene. 

Bell. — " Swelled glands, preventing the patient from open- 
ing his mouth without difficulty and pain ; pharyngeal mucous 
membrane dark cherry-red, and shining as if varnished ; swell- 
ing great, especially in the region of the tonsils ; breathing 
embarrassed and swallowing difficult ; throat painful and shoot- 
ing pains aggravated by swallowing; burning heat and dryness." 
(Nichol.) 

Canth. — " Swelling with erysipelatous flush and turgid veins 
across the fauces; swelling of tonsils." (Allen's "Hand-book of 
Materia Medica and Therapeutics.") 

Compare carbolic acid, lachesis, mere, sol., rhus tox., and 
terebinth. 

PHLEGMONOUS, PARENCHYMATOUS, CEDEMATOUS, OR SUPPURATIVE 
PHARYNGITIS — HOSPITAL SORE THROAT. 

Although this affection is often described with erysipelas of 
the pharynx, and by some considered the same disease, yet to 
me the outlines are sufficiently distinct to demand separate con- 
sideration. In phlegmonous pharyngitis the mucous membrane 
and submucous and peritonsillar tissues suffer, and abscesses form. 
The affected parts may slough, thereby destroying considerable 
areas. 

Etiology. — The primary causes are sudden chilling of por- 
tions or the entire body, wet feet or clothing, and injury from 
knives, sticks, surgical instruments, caustics, mineral acids, etc. 
The secondary influences are surface erysipelas, acute infectious 



192 DISEASES OF THE NOSE AND THROAT. 

diseases, chiefly scarlet fever; a depressed system from over- 
work, poor or insufficient food, and imperfect ventilation and 
drainage. Its onset is sudden, unless it succeed an acute 
catarrhal pharyngitis. 

Symptoms. — The symptoms are chill, fever, rapid pulse, 
prostration, delirium, aching in the head, neck, and back, and 
stiff and painful pharynx, especially on deglutition. Although 
any portion of the throat may be affected, the faucial region 
usually bears the brunt of the malady. The diseased parts are 
red and swelled ; the secretion, at first scant, soon becomes 
purulent or bloody. Submucous haemorrhages are occasionally 
noted. When the soft palate is attacked, the affected side is 
bright-red and bulges forward, the uvula is cedematous, but the 
tonsils may be only slightly inflamed ; on the other hand, they 
are sometimes greatly enlarged, phlegmonous, and press upon 
the post-pharyngeal wall, preventing nasal and oral respiration. 
When peritonsillitis or abscess exists, the suffering is greatly 
augmented. The tissues of the mouth are often so infiltrated 
as to prevent inspection. (Edema of the pharynx or larynx 
may occasion fatal dyspnoea. 

The dry sensation first experienced is soon followed by 
thick, ropy, mucous secretion, salivation, loss of appetite, 
nausea, and fetid breath. Pain on swallowing becomes so 
severe as to induce the patient to starve rather than eat, and 
when food is forced down it may be at once regurgitated, owing 
to paralysis. The voice is thick, nasal, or suppressed. The 
epiglottis, ary-epiglottic folds, and ventricular bands may be 
affected by continuity so that respiration is difficult, even im- 
possible. The cervical glands are usually enlarged, painful, and 
very tender. As the disease subsides, resolution may occur from 
re-absorption of the infiltration ; otherwise an abscess will 
follow, and, if not artificially evacuated, the pus, blood, and 
pieces of connective tissue may be gradually expectorated. 
When this form of expectoration begins, the painful symptoms 
usually disappear quite suddenly ; deglutition becomes easy; and 
sleep refreshing. 



THERAPEUTICS OF HOSPITAL SORE THROAT. 193 

Prognosis. — The prognosis is to be guarded in all cases, as 
death may occur from asphyxia due to enlarged tonsils, abscess, 
or laryngeal oedema. Occasionally the abscess burrows toward 
the chest, breaks into the trachea, or causes erosion of the 
carotid ; pyaemia or gangrene may result. When complicated 
by surface erysipelas, the prognosis is very grave. The disease 
is essentially acute, terminating in from five to twelve days, 
though relapse may delay convalescence two or more weeks. 
Suppuration may continue for a long time, and paralysis of the 
pharyngeal and palatine muscles is not infrequent. 

The diagnosis depends, chiefly, upon the objective appear- 
ances and, at first, is often obscure ; even after pus actually 
exists, it is not always easy to locate it ; palpation offers the 
best means of detection. Stoerk recommends that one hand be 
placed under the angle of the jaw and pressure made in order 
to form a support ; the index finger of the other hand is to be 
placed upon the soft palate and tonsil. The bulb-pointed probe 
may be substituted for the introduced finger. 

Treatment. — In the early stage, pain and dryness may be 
alleviated if the patient suck small pieces of ice. Cold cloths 
or a Leiter lead-coil may be used externally. When pus has 
actually formed, steam inhalations and warm gargles are advis- 
able locally, and heat or poultices externally. Internally, hepar 
2 x is almost specific, but, should it fail, careful incision may be 
made with the hope of evacuating the sac. Should laryngeal 
oedema be present, tracheotomy is usually the only relief, though, 
if swelling of the superior passage be not too great, scarification 
or intubation may act more satisfactorily. If the tonsils inter- 
fere with respiration, it may become necessary to amputate them, 
although puncture is usually sufficient. 

Therapeutics. 
Ailanthus. — " Throat livid, swollen ; tonsils prominent and 
studded with deep ulcers, oozing a fetid, scanty discharge; 
external neck swollen." (Hering's "Guiding Symptoms.") 



194 DISEASES OF THE NOSE AND THROAT. 

Compare apis, iodine, kali mur., mere, hepar, and the 
" Therapeutics " of the following subject. 

GANGRENOUS, MALIGNANT, OR PUTRID SORE THROAT. 

Etiology. — This affection was formerly classed with diph- 
theria, but the lines of demarcation are well drawn ; it is a rare 
condition, — the result of blood-poison. Gangrenous sore throat, 
strictly speaking, is primary, and not the result of such pharyn- 
geal changes as accompany scarlet fever, diphtheria, erysipelas, 
retropharyngeal abscess, scurvy, typhoid fever, phlegmon, etc. ; 
the gangrene associated with those conditions should be consid- 
ered as secondary. 

It starts as a severe inflammation, which speedily assumes 
the gangrenous form ; although this change often occurs so 
quickly that its gangrenous nature is sometimes apparent at the 
first examination. 

The affection invades both the mucous and submucous 
structures, but does not attack the muscles, which may, how 
ever, be softened and exposed on account of the destruction of 
the overlying tissues. The gangrenous mass may be small, cir- 
cumscribed, dirty yellow, and oval or circular. After the spha- 
celus has come away, the edges of the depression are perpen- 
dicular and the surface covered with a delicate pseudomembrane. 

Symptoms. — The throat symptoms may be preceded by 
fever and malaise, but generally dryness, burning, stiffness, and 
aching in the pharyngeal region first call attention to the 
malady. In two or three days gangrene may have supervened, 
with loss of some of the pharyngeal tissue. The cervical glands 
are often involved and the tonsils greatly enlarged, perhaps gan- 
grenous. The early objective symptoms are not characteristic, 
but the putrid odor is often one of the first, and, later in the 
affection, becomes almost unbearable. When the disease is 
established, the pharynx, tonsils, uvula, and soft palate may be 
covered with discolored patches, raised somewhat above the sur- 
rounding surface. These soon change, become dark, almost 



GANGRENOUS, MALIGNANT, OR PUTRID SORE THROAT. 195 

black, and are exfoliated, leaving an ulcerated surface. If the 
disease still progress the mouth, nose, larynx, trachea, oesopha- 
gus, stomach, and the entire alimentary tract may participate in 
the gangrenous process. Swallowing is very painful, almost 
impossible from the first ; and vocalization and respiration are 
impaired as soon as the interior of the larynx is affected. 

The general economy early feels the influence of the fatal 
malady. The vital forces fail, prostration is marked, the pulse 
and temperature rise, but soon a state of collapse occurs, with 
decrease in the heart's frequence and a depression of bodily 
temperature below the normal. The pulse may be exceedingly 
slow (in one case reported by Gubler it was only fifteen beats 
per minute), and the feebleness of the circulation is pictured in 
the pale, bluish, cold exterior in which the extremities, espe- 
cially, participate. The face is not unlike that seen in the 
collapse of cholera. 

When the lungs are affected, haemorrhages and pneumonia 
follow ; when the alimentary tract is diseased, diarrhoea and 
haemorrhages result ; and when the larynx is cedematous, 
dyspnoea may prove fatal in a few minutes. The abdomi- 
nal and thoracic organs may suffer in general; the super- 
ficial veins be phlebitic ; or bleeding may occur from the nose, 
ears, mouth, pharynx, lungs, bowels, and bladder. Although 
the patient may die from coma, syncope is the usual form of 
death. 

Diagnosis. — The diagnosis is not usually very difficult, 
although diphtheria bears some points of resemblance. In diph- 
theria the odor is different from that of gangrenous sore throat, 
and is less intense, especially at the beginning of the attack ; the 
membrane is whitish, yellowish, or, at a later stage, dirty yellow, 
and not raised above the surrounding membrane : in gangrene 
the deposit is dark from the first, and soon gives place to an 
ulcer. In diphtheria the cervical glands rarely escape ; in gan- 
grene, frequently. In diphtheria there is prostration, with con- 
tinued increase in the pulse and temperature ; in gangrene there 



196 DISEASES OF THE NOSE AND THROAT. 

is, at the outset, greater prostration, with subnormal pulse and 
temperature. 

Prognosis. — This is generally grave ; it is greatly depend- 
ent upon the intensity of the blood-poison. Death usually 
occurs in a few days. 

Treatment. — The management of putrid sore throat must 
be actively disinfectant and medicinal. Disinfectants are best 
applied as spray or gargle, and should consist of peroxide of 
hydrogen, permanganate of potassium, or boric acid. Internally, 
concentrated, nutritious diet should be administered, and stim- 
ulants occasionally given. Nutritive enemata are frequently 
required to aid the food taken into the stomach, especially if 
deglutition be greatly impaired. If oedema of the larynx occur, 
even scarification, intubation, and tracheotomy offer slight hope. 

Therapeutics. 

Ailanthus. — Throat gangrenous, livid, puffed ; tonsils cov- 
ered with confluent ulcers, which ooze a scanty, fetid discharge ; 
throat covered with a dark-brown membrane ; greenish expec- 
toration ; dark-colored haemorrhage ; cannot swallow anything ; 
neck swelled, mottled, and very sensitive to contact. 

Ammon. carb. — Gangrene of tonsils, which are bluish; ulcers 
violently painful ; burning in pharynx ; drowsiness and stupor. 

Ars. — Throat burns like hot coals ; tonsils dark-red, swelled, 
gangrenous ; vesicles in the pharynx ; paralysis of the pharynx 
and soft palate ; fluids pass into the nose ; malignant cases (ars. 
iod.) ; restless, anxious, prostrated. 

Bap. — Painful, dark, putrid ulcers ; throat dark-red, feels 
constricted ; burning rawness ; profuse, viscid mucus, which can 
neither be swallowed nor expectorated ; rattling in throat ; 
salivation ; stupor ; low, muttering delirium. 

Bell. — Neck so stiff that the head cannot be rotated; great 
prostration and fever ; heavy pain in the throat ; mucous mem- 
brane deep-purple, almost black ; oedema of epiglottis and 
ary-epiglottic folds. 



THERAPEUTICS OF GANGRENOUS SORE THROAT. 197 

Carbo veg. — Rapid loss of strength ; cold breath and ex- 
tremities ; clammy perspiration, but with a desire to be fanned ; 
sloughing of the faucial tissues. 

Silica. — Gangrene especially of tonsils ; deep ulcers. 

Compare ars. iod., cinch., iod., kali mur., kali phos., and 
natr. ars. 



CHAPTER XVI. 

Abscess, Ulceration, Parasites. 



RETRO- OR POST- PHARYNGEAL ABSCESS. 

Etiology. — Abscess in the tissues of the posterior wall of 
the pharynx may be either idiopathic or secondary ; the former 
is usually found in young children, mostly under one year of 
age, and often has for its origin rickets, tuberculosis, syphilis, 
scrofula, or lymphadenitis. These lymphatic glands are of 
considerable size in infancy, but usually disappear soon after 
the fifth year (Henle). Secondary abscess occurs at any age, 
but chiefly in childhood, and may originate in caries of the 
bodies of the cervical vertebrae ; but usually in an inflammation 
of the post-pharyngeal glands (lymphadenitis), phlegmonous 
pharyngitis, diphtheritic and ©edematous pharyngitis, scarlatina, 
and suppurative otitis media. Traumatic abscess is usually due 
to scalds, burns, or thrusts of instruments, sticks, etc. 

Sometimes the abscess develops very gradually, occupying 
two or three months, in which case it is usually secondary ; or 
it may appear suddenly, in two or three days, — usually idio- 
pathic, but occasionally secondary. 

Symptoms. — The first symptoms calling attention to it are 
dysphagia and odonphagia ; later it is difficult to open the 
mouth widely, the cervical glands become enlarged and painful, 
food regurgitates through the nose or passes into the larynx, the 
voice becomes nasal or, more properly, guttural, and nasal 
respiration is impeded or even impossible. If the swelling be 
situated in the region of the larynx there is apt to be dyspnoea, 
when the condition is sometimes mistaken for croup ; but it 
will be noticed that in post-pharyngeal abscess there is rarely 
cough, although frequent efforts are made to clear the throat ; 
neither is the voice croupv, but naso-guttural. The larynx is 
(198) 



POST-PHARYNGEAL ABSCESS. 199 

occasionally involved secondarily. In the more chronic form 
there is rarely any pain, but in the acute variety it is quite 
intense and often throbbing and lancinating. The head is apt 
to be turned toward the side less affected, or if the abscess 
be in the median line the head may be thrown forward and can 
only be raised with difficulty. If the abscess be due to spinal 
caries, rotation of the head is very painful. The patient is 
much prostrated and a typhoid condition is frequent ; with 
children convulsions may occur. Occasionally when the abscess 
bursts it floods the larynx and parts below, sometimes causing 
suffocation. In other cases death is due to asphyxia, the result 
of cedema or abscess of the larynx. 

The disease is liable to be mistaken for a soft tumor, but 
in that condition the sense of fluctuation is wanting, except in 
hsematoma. In some instances the first impulse is to diagnose 
an inflammatory affection of the soft palate, on account of its 
redness and swelling, but this is easily corrected by passing the 
finger into the post-palatine space, when the swelling and 
perhaps the fluctuation may be detected back of the curtain. 
If the patient be old enough to examine with the rhinoscopic 
mirror, the nature of the swelling can be determined by inspec- 
tion. The abscess is dusky red, and imparts a boggy sensation 
to the finger. Although the pus usually forms in the posterior 
wall of the pharynx, it sometimes occupies the sides ; whatever 
its position, there is danger that it may burrow down the tissues 
of the throat or neck, causing serious damage by pressure ; but 
it may find an exit on the skin surface, forming a fistula. 

Prognosis. — The prognosis is very grave in secondary cases, 
the intensity depending, very often, upon the original affection. 
In idiopathic cases, the prognosis is generally good, if the treat- 
ment be prompt ; otherwise, death may occur from spontaneous 
rupture and suffocation. 

Treatment. — As soon as pus is detected the abscess should 
be opened, either with a knife or trocar ; the incision being made 
as nearly as possible in the median line, lest the internal carotid 



200 DISEASES OF THE NOSE AND THROAT. 

be injured. In making the puncture the instrument should never 
penetrate far beyond the anterior abscess-wall, else the posterior 
wall, the vessels, or even the parts directly surrounding the 
vertebrae might be injured. The patient's head should be well 
thrown forward before the incision is made, that the pus may 
find an exit through the mouth or nose and not pass into the 
larynx and trachea ; for a similar reason, it is better to make a 
small incision at first and, if necessary, enlarge it afterward. 
When the pus is evacuated by the trocar this danger is obvi- 
ated, but, as the tissues are rather resistant, they may slip from 
the point of the instrument and serious, if not fatal, damage 
result ; on the other hand, the point may penetrate too far and 
do harm. These dangers, however, can usually be overcome by 
the use of a curved trocar-cannula, so that the puncture may 




E A.YAPMALL"CC:PH[LA 



Fig. 64.— Ccrved Trocar-Cannila. 

be made in a nearly vertical direction. Hilton and, later, Chiene 
recommended evacuation by dissection behind the sterno-mastoid 
muscle. 

In the early stage, remedies will often obviate the necessity 
for operative measures, chief of which are bell., hepar, and 
mere. ; after evacuation of the pus, hepar, kali mur., puis., and 
silica. 

General treatment and hygienic care are very important. 

ULCERATION OF THE PHARYNX. 

Pharyngeal ulceration may result from syphilis, phthisis, 
scrofula, cancer, lupus, leprosy, injuries, scalds, burns, corro- 
sives, diphtheria; scarlet, typhoid, and typhus fevers; erysipelas, 
phlegmonous pharyngitis, glanders, acute follicular pharyngitis, 
herpes, etc. ; lately Heryng has described an idiopathic (?) form. 



PARASITIC DISEASES OF THE PHARYNX. 201 

PARASITIC DISEASES OF THE PHARYNX. 

Parasitic affections of the pharynx are quite rare, even in 
children, in whom the parasites generally extend from the 
mouth. In adults these affections are usually primary. Such 
diseases appear when the patient's mucous membranes furnish a 
suitable soil for the development and propagation of the special 
micro-organisms-. The parasites appear in the form of tufts, 
lumps, nodules, etc., according to their nature and character- 
istics ; in some cases they are entirely benign, in others by no 
means harmless. The epithelium and mucous membrane are 
the structures usually invaded, but some of the varieties burrow 
deeper, and may even attack the muscles. 

Thrush is the most frequent parasitic affection, and is so 
mild that its presence is often overlooked. In other cases the 
symptoms are more pronounced; the pharynx may feel dry, 
burn, smart, or there may even be sharp pain ; digestion is often 
impaired and deglutition greatly hindered. There may be 
febrile action and malaise, but the general system rarely par- 
ticipates, unless the attack be due to some severe systemic 
affection. 

Diagnosis. — The diagnosis is usually easy, but it is not 
impossible to confuse parasitic conditions with diphtheria, fol- 
licular pharyngitis, follicular tonsillitis, or even with tonsillar 
concretions. It is to be distinguished from diphtheria by the 
absence of fever, restlessness, and prostration, although in 
severe cases it is possible for the general system to be so 
involved as to present some prostration ; in diphtheria, again, 
the pseudomembrane is usually in larger masses, and there is 
greater involvement of the surrounding mucosa. In follicular 
pharyngitis the cheesy material can be wiped away, showing the 
enlarged, open-mouthed follicles. In follicular tonsillitis there 
is severe pain in the throat and back of the neck, and it is 
usually possible to pass a probe into the lacunse, or to withdraw 



202 DISEASES OF THE NOSE AND THROAT. 

some of the folliculous material. Concretions are intensely 
hard, and can usually be moved with a probe. 

Prognosis. — The prognosis is generally good, but it is often 
a very difficult matter to remove the tendency to the development 
of these parasitic masses. Recurrence is prompt after removal 
with knife or scissors, and ordinary antiseptics are powerless. 
If an enlarged tonsil alone be involved, it may be excised. If 
the condition be benign, no mechanical measures are to be 
advised, and in all cases internal remedies should be our chief 
reliance, as the condition is merely a local manifestation of a 
more general change. 

Treatment. — The constitutional treatment should consist 
of proper diet and hygiene and the administration of the 
appropriate remedies, borax heading the list. 

Mycosis is a painless and rare affection. Its favorite site 
is the crypts of the tonsils, during chronic lacunar inflamma- 
tion ; in the latter stage of acute tonsillar affections, the parasites 
may be found at the base of the tongue, between the tonsils and 
half-arches, or in the crypts of the tonsils. They appear as 
white or yellow deposits, not unlike diphtheria, but, when 
uncomplicated, are devoid of pain or inflammation, and impart a 
sensation of hardness. Although promptly destroyed by the 
galvano-cautery, they may recur, if there be an irritation such 
as lacunar concretions or deposits, sharp-angled teeth, etc. 



CHAPTER XVII. 

Exudative Pharyngitis. 



herpes. 

Etiology. — As a result of cold during the changeable 
weather of autumn and spring, herpes may develop in the 
pharynx, in all essential respects like that condition when found 
upon the skin, with which pharyngeal herpes is usually asso- 
ciated. Many authors believe it associated with neurotic tem- 
peraments. It is rather rare, and is most frequently found in 
women and children and in those who are weak and delicate, 
although it may attack the robust individual when mentally or 
physically prostrated. Syphilitic patients frequently have con- 
comitant herpes. 

Feron has suggested an association between mental emo- 
tions and herpetic pharyngitis ; Bertholle believes in its connec- 
tion with uterine and menstrual disturbances; and Herzog 
bases his theory of a neurotic origin on its one-sided manifesta- 
tion, its unilateral headache at the beginning, and its post- 
herpetic paralysis of the soft palate. The use of condiments has 
a decided influence upon the appearance of pharyngeal herpes, 
and, as suggested by Trousseau, the affection is sometimes seen 
during epidemics of diphtheria. 

Pathology. — Pathologically, the only noticeable difference 
between this disease and herpes of the skin is that the process 
which causes the cutaneous crusts may here occasion a pseudo- 
membrane. 

Symptoms. — Symptomatically, herpes is frequently ushered 
in by unilateral headache, malaise, and chilliness ; later, there 
appear salivation and heat, pain, and soreness in the pharynx y 
aggravated by deglutition. The pharynx, at first, presents a 
number of small whitish vesicles, which may be single or 

(203) 



204 DISEASES OF THE NOSE AND THROAT. 

grouped. The faucial region is the part chiefly involved, 
although scattering vesicles are frequently found on the posterior 
pharyngeal wall. The whole number of vesicles varies from 
one to thirty or forty ; at the base of each the mucous mem- 
brane is red and tumefied, while each summit presents a 
dark spot ; although generally unilateral, both sides may be 
attacked. 

The duration of the affection is from four to fourteen 
days, although the vesicles generally disappear in from twenty- 
four to forty-eight hours ; but they may recur in crops. These 
vesicles disappear by absorption ; by rupture, ulceration, and 
speedy cure ; or by rupture, deep ulceration, and the establish- 
ment of a false membrane, chiefly upon the palate, rarely on 
the pharynx. The ulcers and pseudomembrane usually disap- 
pear in three or four days. 

Diagnosis. — The diagnosis is simple, in most cases. It is 
sometimes difficult, however, to differentiate this affection from 
diphtheria, although, if early seen, the vesicles render the 
diagnosis certain ; but where there are several patches of false 
membrane the diagnosis is difficult, if not impossible. Peter 
gives two indications for the identification of herpes : (1) the 
presence of small ulcers, and (2) small, circular spots of trans- 
parent pseudomembrane. To these should be added its frequent 
association with herpes of some other portion of the body ; on 
the other hand, it is not improbable that the herpetic condition 
may co-exist with diphtheria. The latter has submaxillary and 
cervical adenitis, herpes submaxillary. Finally, during epi- 
demics of diphtheria the milder affection may give place to the 
graver. 

Prognosis. — The prognosis is good if the preceding trans- 
formation be excepted. 

Treatment. — The treatment is chiefly constitutional, but 
some soothing application is often beneficial. At times, steam 
inhalations lull the pain. When the membrane loosens, it may 
be necessary to use disinfectants to neutralize the odor. 



ACUTE MEMBRANOUS (CROUPOUS) PHARYNGITIS. 205 

Therapeutics. 

Apis. — -Clusters of vesicles, filled with clear lymph on 
posterior wall of pharynx. Throat puffy and shining as if 
varnished. 

Caps. an. 6 x. — A clinical observation only. Stinging and 
burning in the soft palate and fauces ; on the right side of the 
soft palate, near the base of the uvula, two well-defined herpes, 
which appeared as though covered with a pea-green fungus. 

Compare aeon., ars., clematis, conium, graph., iris, lach., 
lycop., natr. m., natr. sulph., phos., staphis., etc. 

Pemphigus of the pharynx is either an independent affec- 
tion or is a forerunner of the cutaneous form. Its etiology is 
not clear in all cases, although it is usually applied to syphilis 
or to uterine disorders. Its beginning is like herpes. The 
vesicles (bullee) are much larger than those of herpes, and 
contain a milky-white material resembling a false membrane ; 
like herpes, ulcers follow rupture. The larynx may participate, 
resulting in altered function. 

Pustules are rare except in variola or as the result of herpes 
or pemphigus. 

Aphths consist of an inflammatory change with a fibrinous 
deposit upon the mucous membrane. 

They occur chiefly upon the fauces, less often upon the 
pharynx, and rarely upon the larynx. Aphthae are either acute 
or chronic. In either there are burning, shooting pains, worse 
during functional activity. The deposits are apt to be mistaken 
for mucous patches. 

ACUTE MEMBRANOUS (CROUPOUS) PHARYNGITIS. 

Etiology. — The diagnostician is often greatly puzzled to 
distinguish this benign affection from diphtheria. Like the 
latter, simple membranous pharyngitis occurs in those who are 
in a weakened condition ; who have been thrown in contact 
with contagious diseases, more especially diphtheria ; and who 



206 DISEASES OF THE NOSE AND THROAT. 

have been subjected to the influence of putrefying matter or bad 
ventilation. 

Pathology. — Pathologically, membranous pharyngitis dif- 
fers little from diphtheria, although in the former the pseudo- 
membrane forms upon the mucous lining, whence it is easily 
removed ; whereas in the latter it penetrates the mucosa, and is, 
therefore, difficult to remove, and, if torn away in the earlier 
stages, the tissues bleed freely, although, at a later period, the 
membrane of diphtheria peels off quite easily. 

Symptoms. — The affection is often ushered in with a chill 
and slight rise in temperature ; headache and sore throat are 
early symptoms. On inspection the throat is seen to be 
inflamed, more especially in the areas which are to become 
covered with membrane. Its favorite seat is on or near the 
tonsil, although the back of the pharynx is often slightly cov- 
ered. As the early diagnosis is frequently uncertain, such cases 
should be watched very carefully and the precautions noted 
under " Diphtheria of the Pharynx and Larynx " instituted. 

In diphtheria the membrane is frequently rolled up at the 
edges, which is unusual in membranous pharyngitis. In the 
former the membrane generally assumes the color of chamois- 
skin, but may be whitish ; in the latter it is usually white, but 
may be slightly gray or even a little yellow. The extent of 
the deposit has little to do with the diagnosis. In diphtheria 
there is usually a circumscribed red zone ; this is not present in 
non-diphtheritic membranous pharyngitis. 

Prognosis. — The prognosis is good, except that the pseudo- 
membrane sometimes extends to the larynx and causes death by 
suffocation. Although the disease may last two weeks or more, 
it is sometimes cured in a couple of days. 

Treatment. — If the throat be well sprayed a few times with 
a 20-per-cent solution of lactic acid or peroxide of hydrogen, 
the deposit will usually disappear quite promptly. It is not 
necessary to attempt the solution of a slight amount of deposit. 
The best disinfectants are a 10-per-cent solution of permanga- 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 207 

nate of potash, 30 per cent alcohol and water, or lime-water. 
These may be used either as sprays or gargles. Internal rem- 
edies have a well-marked action upon this disease and will 
usually cure it in a few days, but the preceding aids are often 
beneficial. Should the larynx be attacked, the treatment must 
be still more watchful and dyspnoea promptly met by intubation 
or tracheotomy. 

For therapeutics, see end of the following subject. 

DIPHTHERIA OF THE PHARYNX AND LARYNX. 

Despite the vast amount of time and labor bestowed upon 
the practical and theoretical study of diphtheria, too little is 
still known from an absolutely curative stand-point, and it must 
be acknowledged that even the etiology and pathology are not 
clearly understood. 

Etiology. — Diphtheria may be either endemic, epidemic, or 
sporadic. That it is contagious and infectious there seems to 
me little room for doubt ; but there must be a suitable soil for 
its propagation, either in the usual condition of the individual 
or in his temporary state. It may be transmitted from one per- 
son to another or from some of the lower animals to persons by 
contact, the healthy person receiving the inoculation on a 
mucous surface or cutaneous abrasion. There seems little 
doubt that chickens may transmit the affection to human 
beings ; and there is a growing tendency, especially in Europe, 
to attribute the cause of diphtheria in the lower animals to the 
presence of continuous damp soil which is not reached by the 
sun. In speaking of the transmission from cats, Dr. E. Klein 
{The Times and Register, July 19, 1890) says: "The natural 
disease in the cat is, in its symptoms and pathology, a lung dis- 
ease, and it is reasonable to suppose from analogy that the lung 
is the organ in which the diphtheritic process in the cat has its 
seat." 

It is fairly certain that the infection may be carried from 
the cow, so that those who drink the milk are liable to contract 



208 DISEASES OF THE NOSE AND THROAT. 

the disease, and evidence is accumulating to show that it can be 
conveyed through drinking-water. The contagion may be 
received from direct contact of the pseudomembrane (especially 
with grayish-white membrane, less with that which is yellowish 
white), from the presence of the specific products floating in the 
atmosphere, or from contact with clothing or other objects con- 
taminated with the diphtheritic poison. 

One of the recent theories, in reference to diphtheria, is that 
it owes its existence to the chemical products of decomposition. 
Of these, the alkaloid ptomaines have been selected as the 
dread body-guards of the deadly diphtheritic process. They 
are almost always present in diphtheritic membrane, and it is 
thought probable that this chemical product of the putrefactive 
and fermentative vegetable changes is the vehicle of transmis- 
sion through liquids, foods, etc., which have been infected by 
the ptomaines, either from the decomposition of organic life or 
the entrance of these bodies from an actual diphtheritic 
process. 

Recent investigators claim that the Klebs-Lceffler bacilli 
are comparatively innocuous on healthy or unabraded mucous 
membrane, that the ptomaines are the poisonous principle, and 
that, while the bacilli will produce the pseudomembrane, no 
constitutional effects will follow previous to the development of 
ptomaines. Porcelain-filtered diphtheritic fluid freed of the 
organisms, but abounding in ptomaines, will cause death from 
diphtheritic changes without the deposition of pseudomembrane. 
The Klebs-Lceffler bacilli may be detected by staining with 
methyl blue, gentian violet, or by a blue composed of equal 
parts of a watery solution of violet dahlia and methyl green, to 
which sufficient water is added to make a moderate blue 
solution. 

There seems to be little doubt that diphtheria sometimes 
originates independently of such a diseased condition, as many 
good authorities claim that decaying animal or vegetable 
products may generate the disease; but it is more probable that 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 209 

the combination of decaying animal and vegetable material 
is the strongest link in this formative process. 

Those insanitary conditions most prone to produce diph- 
theria are bad sewerage, ill-trapped drains, soil permeated with 
sewer-gas, and drinking-water, milk, etc., rendered noxious by 
admixture with diphtheritic or ptomainic impurities. Diphthe- 
ritically-infected houses or neighborhoods may be rendered non- 
infectious by proper sanitation, and those houses in which the 
disease returns periodically should be thoroughly inspected and 
renovated. It is claimed, on good authority, that the germs 
may remain dormant for years and then be suddenly revivified ; 
the cases thus recorded may now receive a new light from the 
ptomaine theory of production, thereby proving them inde- 
pendent of previous poison ; although the virus which adheres to 
clothing, etc., may remain potent for a long time, often months. 
There seems to be a specific diphtheritic microbe, but every 
diphtheritic patch contains many species of bacteria. Although 
the Klebs-Lceffler bacilli (No. 2) are said by Klein (ibid.) to be 
invariably present in the diphtheritic membrane, neither the 
blood nor the diseased viscera contain them. 

Diphtheria may attack persons of any age, but childhood 
is the most fruitful period. It is not usual during the first year, 
but is most frequent between one and five years of age, after 
which it seems to gradually decline until adolescence ; and it is 
quite unusual in the adult. 

It is often claimed that constitutional conditions have no 
influence upon the appearance of diphtheria, but personal 
observation has led to a different conclusion. Those who have 
catarrhal affections of the upper air-passages, including enlarged 
tonsils, are more ready victims than those less catarrhally 
inclined. Those who are of fine physique, and surrounded by 
luxury and cleanliness, are less apt to suffer endemically ; but 
during epidemics they are little less exempt than those with less 
sanitary surroundings. Season has considerable influence upon 
the disease ; damp, changeable winters are worse than clear 



210 DISEASES OF THE NOSE AND THROAT. 

ones, while summer is a season of comparative immunity. High 
and dry altitudes are generally exempt, but even there fatal 
epidemics sometimes occur. 

Many believe that one attack gives immunity to a second, 
others that one attack renders the patient more susceptible to 
the disease ; but it seems most probable that the patient who 
once suffers is neither more nor less prone to diphtheria, as a 
result of his experience. 

The time of incubation is from two to seven or even four- 
teen days. As a rule, the closer and more continuously healthy 
persons come in contact with the sufferer, the earlier the 
symptoms appear in the one exposed. 

Pathology. — The throat affection starts with an inflamma- 
tion, often mottled in appearance, but soon becoming general and 
extending over large areas of mucous membrane. The deposit 
follows ; beginning at one or more points, it may extend to any 
portion of the respiratory or alimentary tracts, to the lips, eye- 
lids, or skin surface. The mucous membrane undergoes a 
change, whereby patches of exudative products are thrown out 
upon its surface ; a necrotic process soon occurs, followed by the 
development of a pseudomembrane. As a result of fibrinous 
obstruction of the blood-vessels the mucous and fibrinous 
degeneration — deposit — soon yields to circumferential necrosis, 
and later to fatty changes, with separation of the pseudomem- 
brane. The membrane presents, microscopically, two distinct 
layers, even before the stage of separation. The superficial 
layer contains epithelial cells, evidently from the mucous mem- 
brane, which have undergone proliferation, cloudy swelling, and 
mucoid and granular degeneration of the cell contents. Next 
to this is often a net-work of interlacing fibrillae (coagulated 
fibrin) inclosing leucocytes, beneath which is the basement 
membrane. Since the pseudomembrane infiltrates the tissues, 
the necrotic process may destroy the superficial structures, so 
that ulceration frequently follows the separation of the false 
deposit. It is believed by many recent pathologists that the 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 211 

disease is primarily local ; soon, however, the microbes multiply, 
are carried into the circulation, and involve the lymphatic 
vessels ; the entire system is speedily impregnated, the resultant 
ptomaines giving rise to blood-poison and adynamia. The heart 
is affected later and death follows unless something be done to 
relieve the blood of the ptomaines and prevent the formation of 
fresh bacilli. Post-diphtheritic paralyses are thought to be the 
result of this ptomainic influence. Judging from personal 
clinical experience, I can but agree with many close observers, 
and express my belief that the disease is constitutional. 
Although strictly an acute malady, chronic cases have been 
recorded. 

Symptoms. — The symptoms vary with the age of the 
patient and the severity and progress of the attack. In young 
children they often appear suddenly, with marked lethargy, 
indifference, indicative of a violent constitutional disease (septic 
diphtheria), but the onset is usually more gradual and more 
suggestive of a local affection (fibrinous diphtheria). In the 
rapid onset the patient complains of malaise ; feverishness ; 
pain in the neck, back, throat, and head ; the lips are dry, and 
there is pain on deglutition. Nausea, vomiting, and diarrhoea 
may occur. Cutaneous eruptions (erythema, urticaria, petechiae) 
and ecchymoses are frequent. The face may be flushed, the 
pupils dilated, and the expression one of impending illness. 
The throat is congested in the onset, but does not show any 
signs of exudation until some hours later. The pulse may be 
rapid and hard, and the mercury register 103° to 106° F. ; as a 
rule, however, the fever is very mild at first, and the chief symp- 
tom noted is a marked loss of strength with complete indiffer- 
ence to everything. An early examination may indicate a mild 
angina, and usually an enlargement of the cervical glands. 
Later the throat swells, the aching and pain in the throat and 
neck increase, deglutition becomes painful or difficult, and exu- 
dation appears ; at this stage there is usually backache. The 
glands below the angle of the jaw, the submaxillary, and the 



212 DISEASES OF THE NOSE AND THROAT. 

cervicals swell and become tender. The pulse remains above 
normal, but for one or two days the temperature often falls, to 
rise again. As the disease progresses, the symptoms of the two 
forms run more parallel, but may be widely different in inten- 
sity : the originally mild case may become the more severe, or 
the reverse order may obtain. The often scanty, thick, milky, 
brown, or bloody urine should be repeatedly examined for albu- 
min, blood, and tube-casts; urremia may thus be anticipated. 
The kidneys are only hypersemic at first, but later a true paren- 
chymatous nephritis is not infrequent. Haemorrhages may 
occur both in the kidneys and spleen. 

The pharynx, tonsils, or half-arches are usually studded 
here and there with patches of deposit, but the exudation may 
completely cover these parts, even extending to the mouth, 
Eustachian tubes, nose, accessory cavities, larynx, trachea, and 
bronchi, or to the oesophagus and thus through the alimentary 
canal. The membrane is usually white at first, but often 
becomes yellow, dirty brown, or even black. The patient gen- 
erally has much difficulty, and sometimes pain, in deglutition, 
but in mild cases the act is little impeded. Sometimes food 
regurgitates through the nose or passes into the larynx. The 
voice is often thick, nasal respiration impeded, and, if there be 
much swelling about the isthmus of the fauces, the passage of 
air to the larynx will be impaired or prevented. The glands 
are frequently so enormously swelled as to obliterate the out- 
line of the lower jaw ; sometimes, however, they are enlarged 
in chains or beads. As a rule, the glandular involvement keeps 
pace with the development of the membrane, and as the latter 
diminishes the former usually recedes. If long and severely 
swelled, the glands may break, giving rise to a sanious dis- 
charge. The patient is greatly prostrated ; the lips and tongue 
are dry, the latter often heavily coated, whitish or brown ; and 
the breath often pathognomonically offensive, yet it may be 
without appreciable fcetor. Frequently the patient's only com- 
plaint is of prostration and a dryness of his tongue and lips, 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 213 

which may be cracked and bleeding, and at which he may pick 
continually. This dryness is often augmented by the enforced 
mouth-breathing. Semiconsciousness may follow, and the sleep 
be restless and delirious. Suppuration of the tympanum is 
frequent. 

If the severe symptoms continue the patient's strength 
will fail, the pulse grow weak and fluttering, respiration rapid 
and superficial, the face haggard and ashy, the discharge from 
the mouth become thin and ichorous, the eyes look sunken and 
glassy, the fcetor of the breath become more pronounced, the 
constrictor muscles cease to contract, the urine and faeces pass 
involuntarily, and the temperature fall, — all indicative of a 
grave termination. Finally, cyanosis may supervene, collapse 
follow, and the patient die while in a comatose state. In other 
cases the temperature falls precipitately ; the patient becomes 
blanched and dies suddenly from paralysis of the heart. 

In those cases in which the termination of pharyngeal 
diphtheria is favorable, the pulse and temperature gradually 
fall; in from three to six days the prostration, strength, and 
appetite improve ; the membrane exfoliates, leaving a denuded 
surface and often increased pain on deglutition ; the glands sub- 
side ; the breathing becomes more natural with the decreasing 
restlessness ; and the gradual improvement of the patient is aug- 
mented by quiet, refreshing sleep. The throat clears up, and 
the parts gradually assume a natural appearance, provided the 
ulceration has not been so extensive as to continue after the sub- 
sidence of the more acute symptoms. The tonsils often remain 
enlarged, but previously hypertrophied tonsils may be left in a 
comparatively normal condition. It is not unusual, however, 
to find various sequelae, especially paralyses. Even when 
apparently convalescent, the heart may suddenly cease beating, 
usually owing to some exertion or emotion, and the patient fall 
lifeless. In mild cases the patient may begin to recover in three 
or four days ; but, if severe, the symptoms may be prolonged 
many weeks, owing to the various complications, and the mem- 



214 DISEASES OF THE NOSE AND THROAT. 

brane may re-form six or eight times. Occasionally, after all 
deposit has disappeared and hopes of a speedy recovery are 
entertained, the pseudomembrane may re-form and be worse 
than at any previous time. 

Diphtheria of the pharynx sometimes assumes a gangrenous 
form, whereby large areas of the affected parts may slough. In 
this condition the patient is very adynamic and the grade of 
inflammation is apparently much more severe than in non-gan- 
grenous diphtheria. In this variety the breath and discharges 
are almost unendurable, the patient loses all appetite, and 
usually dies in from two to eight days from implication of the 
heart, carbonic-acid poison, coma, paralysis, or oedema of the 
lungs. In this form of the disease, the kidneys are nearly 
always greatly affected ; albuminuria is usually present ; there 
are loss of appetite, nausea, and vomiting, with suppression of 
urine, terminating in uraemia with convulsions, or coma and 
death. (Edema is rare. The albuminuria may assume the 
chronic form with the presence of fatty matter and various 
tube-casts, indicating the existence of an interstitial, parenchy- 
matous nephritis ; uraemia may follow this condition and con- 
stitute one of the sequelae of diphtheria. 

If the membrane extend to the nose the nasal secretions 
become ichorous, nasal respiration embarrassed according to the 
amount of membrane and swelling, and the case only too often 
proves rapidly fatal. It may recover, however, with temporary 
paralysis of the soft palate and palato-tubal muscles. 

It is not very unusual for the diphtheritic membrane to 
attack the genitalia or an abraded skin surface ; it has also been 
observed on the healthy skin. If the membrane extend to the 
oesophagus and stomach, the appetite is lost and the patient is 
unable to swallow. The entire alimentary tract may suffer 
and an exceedingly offensive, watery, green, yellow, or bloody 
diarrhoea supervene, and contain shreds or even casts of 
membrane. 

The larvnx is usually involved by extension from the 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 215 

pharynx, but Schech states that " Extension downward is what 
■usually occurs ; but the process may begin in the trachea and 
larynx and spread upward, as I have myself repeatedly seen." 
When the membrane extends to the larynx, usually from three 
to ten days (occasionally earlier) after its appearance in the 
pharynx, a slight vocal roughness or hoarseness in speaking, 
crying, or coughing may first call attention to it. This hoarse- 
ness may be so slight as to scarcely attract the attendant's 
notice, but which, to the practiced ear, indicates a future 
struggle. If it be possible to use the laryngoscope at this stage, 
the larynx will be found somewhat congested, but there may 
be no pseudomembrane. In a few hours or a day or two the 
hoarseness will probably be more evident or even permanent, 
and the cough distressingly hard and barking. At this stage 
laryngoscopic examination reveals a deposit, either on the epi- 
glottis or, more usually, on the ventricular bands or inter- 
arytenoid fold. It may be in small, thin flakes or be thick, 
yellow, or brown and cover a large part of the lining membrane. 
Respiration soon becomes quick, superficial, and difficult ; 
the patient anxious, the pulse rapid and thin, the voice lost, 
although croupy cough may continue. If the condition 
advance still further, the muscles of the neck and chest are 
violently contracted in the effort to inspire, the epigastrium and 
supra-sternal notch are greatly depressed, the eyes staring, and 
the head and body often bathed in cold perspiration. The 
breathing is noisy, whistling, harsh, rasping, or sawing accord- 
ing to circumstances, and can sometimes be heard all over the 
house. The sufferer grasps at his throat to loosen all clothing, 
or he may even try to tear the throat open ; he rolls his head 
from side to side or throws it back ; he is restless ; wants to sit 
up, or to be lifted up and immediately laid down again. At 
times inspiration alone is affected, but, as a rule, both inspira- 
tion and expiration are stridulous. Although, after it is once 
affected, breathing is rarely normal, it is much easier at times, 
and the hope is only too often entertained that the patient is 



216 DISEASES OF THE NOSE AND THROAT. 

recovering. Auscultation will frequently reveal the presence of 
obstruction in the trachea, and even the bronchial tubes may be 
the seat of deposits, as evinced by the fine crepitant rales heard 
all over the upper chest. 

If the membrane loosen, large shreds are often expectorated 
and even partial casts of the trachea and bronchial tubes may 
be coughed out. If the patient recover, which is not impos- 
sible even after the existence of severe dyspnoea, the membrane 
is dislodged and expelled, the breathing becomes freer, the voice 
gradually grows less hoarse, and the patient becomes easier and 
is able to sleep comfortably. Convalescence is usually gradual 
and may be interrupted by a return of the symptoms, from 
which the sufferer may succumb. In fatal cases the cough 
becomes less hoarse and barking, or may be suppressed ; the 
voice is extinct ; the breathing exceedingly labored ; the pulse 
weak ; the eyes lustreless ; the veins in the neck greatly dis- 
tended ; the lips and finger-tips bluish, cyanotic ; the surface ot 
the body bathed in cold perspiration ; the feet and legs cold ; 
and stupor supervenes. This state passes into somnolence, coma 
follows, and, unless respiration be mechanically relieved, death 
is the usual result. 

In adults the greater width of the larynx and trachea ren- 
ders the severe symptoms less frequent than in children, although 

where there is a larsre amount of false membrane or a consider- 
ed 

able degree of infiltration or oedema, the same symptoms may 
arise and death follow. Although false membrane is frequently 
found in the trachea at the time of tracheotomy, the deposit is 
apt to become more extensive in this passage and in the bron- 
chial tubes after the operation. After tracheotomy an increase 
in respiratory difficulty is indicative of an obstruction in the 
tracheotomy-tube or an extension of the membrane to the 
deeper parts, with a decrease in the amount of the discharge 
from the cannula, increase in the cough, and a rise of tempera- 
ture. If the latter complication exist, the patient soon becomes 
cyanotic and passes through the stages already noted as causing 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 217 

death. Dr. J. O'Dwyer {Jour, of the Resp. Organs, June, 1890) 
says that in no other acute disease of the larynx is there 
"excessive tumefaction and rigidity of the epiglottis as conveyed 
by the sense of touch." 

Sequelae,. — Cardiac complications are not rare, and, after 
recovery seems assured, many patients die from sudden paralysis 
of the heart, fatty degeneration of the heart-muscles, or throm- 
bosis of the ventricles, assisted by paralysis of the vagus and 
cardiac ganglion. As a rule, the termination is sudden and 
unlooked for, but sometimes the patient may survive a number 
of hours or even a few days, after the first appearance of the 
cardiac changes. These usually occur as palpitation, very rapid 
pulse, asthmatic respiration, and gradual collapse. Myocarditis 
is also a complication of rather frequent occurrence, from which 
the patient may recover after some weeks or months ; but such 
complications usually prove fatal from dropsy or paralysis of the 
heart. Perichondritis of the larynx occasionally follows pro- 
tracted diphtheria. 

The sequelae of tracheotomy are : permanent use of the 
cannula, on account of paralysis of the posterior crico-arytenoid 
muscles (abductors) ; laryngeal or tracheal strictures, following 
ulceration either of diphtheritic or traumatic origin ; or the 
presence of a tracheal fistula from sloughing of the tissues 
about the tracheal wound, due to erysipelas or secondary diph- 
theria of the incision. A speedier and more serious sequel may 
be pneumonia, as already suggested. 

Stenoses of the larynx or trachea need the same care as 
noted under " Stenosis of the Larynx." Otorrhcea, following a 
diphtheritic process of the middle ear, is not an unusual com- 
plication and sequel. 

Paralysis, following acute sore throat, is generally regarded 
as sufficiently pathognomonic of a recent diphtheria to warrant 
such a diagnosis, even if the affection have been very mild and 
without visible deposit both with and without the aid of mirrors. 
It must not be forgotten, however, that paralysis sometimes follows 



218 DISEASES OF THE NOSE AND THROAT. 

other than diphtheritic conditions, especially typhoid fever in 
which there has been a throat complication. Quite recently, 
considerable stress has been laid upon the occurrence of paralysis 
directly following or associated with acute follicular tonsillitis 
In The Hahnemannian Monthly, January, 1891, Dr. Edwin H. 
Van Deusen calls attention to " An Affection of the Pharyngeal 
Muscles Following Follicular Tonsillitis, and Resembling Post- 
Diphtheritic Paralysis." He and others claim paralysis to be a 
sequence of follicular tonsillitis ; while this is probable, it must 
be remembered that it is often exceedingly difficult to make an 
unqualified differentiation between these affections. Palsy of the 
soft palate may follow herpes. 

Paralysis usually shows itself in a loss of motion of the 
soft palate and uvula, whereby speech is defective and nasal 
regurgitation of food frequent. There may be loss of power in 
the ocular muscles, giving rise to impairment in the motion 
of the globes, or the action of the ciliary muscle may be hin- 
dered, giving rise to an enlarged pupil and loss of accommoda- 
tion. Loss of power may occur in some of the muscles of the 
arms and legs, less frequently the constrictor pharyngeal mus- 
cles. Involvement of the superior laryngeal nerves gives rise 
to difficult deglutition, owing to anaesthesia of the mucous 
membrane about the upper portion of the larynx and to loss 
of motion in the epiglottis, whereby it remains in its vertical 
position during deglutition. Paralysis of the larynx is quite 
rare, but may appear and render vocalization imperfect or im- 
possible, or, when the abductor muscles are paralyzed, it may 
so interfere with respiration as to cause severe, or even fatal, 
dyspnoea. The voice may be impaired from paralysis of the 
crico-thyroid muscles (superior laryngeal nerves) or from loss 
of power in the adductors (recurrent laryngeal nerves). Loss of 
motion on the part of the diaphragm is, fortunately, rare, as it 
is one of the most distressing conditions, in that the greatest 
dyspnoea results, owing to its lost action. The respiratory mus- 
cles are rarely affected until some weeks after apparent recovery. 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 219 

Paralyses of other muscles of the body are less frequent, 
but there may be incontinence of urine, rectal sluggishness, 
and impotence. The rarest form of post-diphtheritic paralysis 
is a loss of motion in the muscles of the neck, so that the 
patient cannot move his head from the pillow. 

Most forms of post-diphtheritic paralysis (considered a part 
of the disease, and not a sequel, by Jacobi and W. H. Thom- 
son, of New York) occur two or three weeks after cessation ot 
the active symptoms, but the loss of motion may not be noticed 
for five or six weeks ; on the other hand, it may occur before 
the close of the active condition or even the exfoliation of the 
false membrane. As a rule, these paralyses are self-limiting; 
the milder forms may pass away in from one to ten weeks, 
although they generally require medicinal, electrical, or surgical 
aid. Occasionally the paralysis proves incurable, and death 
may follow. The medicines which have proved most service- 
able are assafcetida, bovista, caust., gels., ignatia, and rhus tox. 
The classic remedy of the dominant school is a hypodermic 
injection of one-sixtieth of a grain of strychnine. Electricity 
may be advantageously applied directly to the affected muscles, 
selecting preferably the faradic current, the negative pole of 
which is to be placed over the affected muscle, the positive else- 
where, but usually held in the hand. When within the phar- 
ynx, larynx, or oesophagus, the laryngeal electrode may be used 
(see "Neuroses of the Larynx"). When deglutition is greatly 
impaired or food enters the larynx from implication of the 
superior laryngeal nerve, the use of the stomach-tube is usually 
essential, as sufficient nourishment can rarely be absorbed from 
rectal enemata or oily inunctions, even were they as desirable as 
stomach feeding. The oesophageal tube should have a funnel- 
shaped top, into which, when properly placed, fluid food can be 
poured. The food should always be warmed, and not given too 
fast ; it is also important to have it very nourishing and concen- 
trated. In most instances, it is better to have it partially pre- 
digested. If dyspnoea be threatening, as a result of paralysis 



220 DISEASES OF THE NOSE AND THROAT. 

of the posterior crico-arytenoid muscles, it is rarely safe to delay 
tracheotomy in the hope of a recovery, as death may occur sud- 
denly, especially if the patient be subjected to fright or vigorous 
physical strain. 

Diagnosis. — The diagnosis of diphtheria is usually a very 
simple matter, but it is sometimes impossible to make a satisfac- 
tory differentiation. In mild cases the disease may be confused 
with parenchymatous or with follicular tonsillitis, herpes, aphtha, 
membranous pharyngitis or tonsillitis, syphilis, phlegmonous 
pharyngitis, or scarlet fever ; this is especially true early in the 
affections. In most cases the subsequent history will quickly 
clear up the diagnosis. The septic and severer forms of diph- 
theria may be mistaken for typhoid fever. 

In acute tonsillitis the tongue is heavily coated white, 
there is usually a high fever, great difficulty in opening the 
mouth, and severe pain on deglutition ; when the tonsil becomes 
very large and gives evidence of pus formation, the diagnosis is 
usually easy. In diphtheria the tongue is usually dry and un- 
coated, the fever less marked, the mouth easily opened, and 
deglutition less painful. 

Diphtheria may usually be differentiated from follicular 
tonsillitis (see the latter affection). It is sometimes most diffi- 
cult to distinguish it from herpes of the pharynx, but the latter 
affection is rare and the herpes usually isolated ; although they 
may be confluent, in which case they are only to be distin- 
guished by the further development of the condition and the 
absence of the Klebs-Lcefrler bacilli and albuminuria. Further, 
there is less constitutional disturbance and the membrane of 
herpes does not spread to neighboring organs. It is distin- 
guishable from aphtha by the absence of fever, pulse accelera- 
tion, prostration, and history. The distinction from scarlet 
fever is difficult ; for both may have a rash and sore throat, but 
the scarlatina angina is usually more diffuse and redder than that 
of diphtheria ; it is without an areola ; the deposit appears 
thick, irregular, as if excavated, with no apparent tendency to 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 221 

spread, and is easily detached from the mucous membrane. 
There is albuminuria in each, but diphtheria does not seem 
to have hsematuria; the prostration of diphtheria is usually 
greater. Finally, the thermometer may register 103° to 105° F. 
continuously in scarlet fever, while, in the affection under con- 
sideration, rarely more than 102° F., and is fluctuating. The 
bacillus of Klebs and Lceffler is found in true diphtheria, but 
in the scarlatinous form only the streptococcus of suppuration. 
According to Tchernaieff {Bulletin Med., No. 28, 1889), the diph- 
theria of scarlet fever shows itself from the third to the fifth 
day of the disease. It never attacks the larynx, but always the 
nasal fossse. It is never followed by paralysis. Histologically, 
the false membranes never show the character of those of true 
diphtheria, consisting only of a granular cell-detritus, and never 
showing the hyaline net-work. The tissues beneath the false 
membrane show only inflammatory lesions. True diphtheria is 
a necrotic process. 

From membranous pharyngitis it is sometimes impossible 
to differentiate it ; but, as a rule, there is less prostration in 
the non-diphtheritic affection ; there is not usually any areola 
surrounding the false membrane, which is whiter in color; 
its edges are not so apt to be curled up; it is not so liable 
to adhere very tightly to the underlying tissues, so that its 
forcible removal is rarely followed by bleeding, although the 
under side of the dislodged pseudomembrane may be blood- 
stained. 

Syphilis may at times complicate the diagnosis, but the 
marked dull areola which surrounds the mucous patch, the 
complete absence of fever, and the history will usually be suffi- 
cient to distinguish the affection. Phlegmonous pharyngitis 
and erysipelas have higher temperatures, greater pharyngeal 
distress, and marked oedema. 

The differentiation between membranous croup and diph- 
theria of the larynx is, according to Gay, of Boston (Kans. 
Med. Jour.), as follows : — 



222 



DISEASES OF THE NOSE AND THROAT. 



CROUP. 

A local disease. 
Begins in the larynx. 
Pharynx slightly affected. 
Not traceable to local causes. 
Seldom occurs in adults. 
Neither contagious nor infectious. 
Not epidemic. 
No affection of lymphatics. 



DIPHTHERITIC CROUP. 

A constitutional disease. 
Begins in the fauces. 
Pharynx extensively affected. 
Often traceable to local causes. 
Not infrequent in adults. 
Both contagious and infectious. 
Often epidemic. 
Lymphatics often affected. 



Kolisko and Paltauf ( Wien. ldin. Woch,, No. 8, 1889) 
say it is not possible to discover any anatomico-pathological dif- 
ference, as Lceffler's bacillus is found in both diphtheria and 
croup. 

From typhoid fever it may be diagnosed by repeated exam- 
inations of the throat, but the general symptoms may be so 
purely typhoid in nature that it is possible for the • physician to 
be thrown off his guard, especially when false membrane has. 
not formed at the time of the first examination ; later, the gen- 
eral symptoms may so far outweigh the local that a subsequent 
examination of the throat may be neglected. 

Whenever diphtheria is suspected, with uncertain diagnosis, 
it is advisable to use both laryngeal and rhinal mirrors, as it is 
not unusual for a false membrane to form out of sight of the 
unaided eye. Repeated examinations of the throat should not 
be neglected in any acute pharyngeal difficulty, as at any time 
an apparently simple disease may develop into a true diphtheria. 

Prognosis. — The prognosis depends upon many circum- 
stances, and, no matter how mild the beginning, the gravest 
complications may arise. It is never safe to promise much until 
the stage of sequelae has passed. The patient may die in 
twelve hours from the first appearance of the membrane, or 
death may be delayed three or more weeks. Infancy and early 
childhood are unfavorable to recovery ; other things being equal, 
the older the patient, the greater the prospect of a cure. The 
nature of the epidemic has great influence on the termination, 
as malignancy is the rule in some, while in others most cases 
recover. Family peculiarities have an apparent influence on the 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 223 

result. Gangrenous diphtheria is very generally fatal. The 
condition most feared is the extension of the disease to the 
larynx, trachea, and bronchi, so frequent in certain epidemics 
and in the so-called " croupous " individual. Early nasal in- 
volvement is unfavorable, as are haemorrhages, ecchymoses, 
purpura, asthenia, septicaemia, marked albuminuria with scanty 
urine, uraemia, and typhoid conditions. Deposit on the hard 
palate, cheeks, tongue, and lips indicates serious consequences. 
Rapid decline of fever, suppression of urine, and cardiac failure 
are too often fatal signs. It is, therefore, very difficult to make 
an exact estimate of the fatality of the disease. In one epidemic 
in Oldenberg, in 1822 {Arch, fur Kinderheilkunde, 1886), it 
was fatal in 55 per cent of the cases, and Mackenzie says " It 
may, perhaps, be laid down as a rule that, of the cases in which 
a definite false membrane is present, one-third, at least, will 
probably prove fatal." Some have gone further and said that 
when the patient recovered the disease was not diphtheria. It 
may be stated that, the more rapid the development of the mem- 
brane and the greater its extension, the graver the case ; also, 
the thicker and darker the false membrane, the greater the 
danger; yet a thin, light-colored membrane not infrequently 
becomes gradually thick and dark, — and this when the patient 
is apparently improving. 

Under homoeopathic treatment the prognosis is not usually 
so bad, yet, in certain epidemics death occurs in, perhaps, one- 
third of the cases, and when the larynx is attacked secondarily 
about one-third of the cases recover. Raue, in the third edition 
of his "Special Pathology and Therapeutic Hints," says: "The 
prognosis of diphtheria, generally speaking, under homoeo- 
pathic treatment, is not bad. Of course we meet difficult cases, 
even fatal ones ; but the percentage of loss is small. Its danger 
lies principally in the possibility of its extension to the larynx, 
and its septic poisoning." 

Treatment. — As soon as diphtheria is discovered the patient 
should be isolated ; all children and those not actually needed 



224 DISEASES OF THE NOSE AND THROAT. 

in the care of the case should be absolutely excluded, and it is 
better that the attendants do not come in contact with other per- 
sons. The sick-room should be light, warm (70° to 75° F.), 
and airy, without draughts. The atmosphere should be kept 
moist, and all unnecessary drapery immediately removed, as it 
may conduce to a later spread of the disease. Disinfectants, 
especially Piatt's chlorides and eucalyptus, should be constantly 
exposed in the sick-room and throughout the house. All dis- 
charges should be disinfected, and handkerchiefs and cloths 
upon which the patient expectorates burned ; wearing apparel 
should be thoroughly fumigated before it is washed. It is pos- 
sible for an uninfected person to carry the disease to others, and 
it also seems possible that the patient may have a second attack 
from too close relationship to drapery, clothing, etc., which was 
infected during the primary disease. It is not certain that par- 
ticles of the diphtheritic virus may not remain dormant in the 
crypts of the tonsils, or in the nasal passages, to spring into 
activity when the system again presents susceptibility to the 
disease. Inoculations for the purpose of rendering animals im- 
mune have succeeded, but I know of no such results in man. 
Cultures have been used successfully by Kitasato and Behring ; 
C. Frankel has shown that these cultures should be heated to 
131° to 140° F. (Berliner Idin. Wochenschrift, No. 49, 1890). 
Subcutaneous injections of a 10-per-cent solution of peroxide 
of hydrogen are said to act prophylactically. 

The treatment of diphtheria is chiefly internal, based 
upon carefully-secured indications, but this should be aided 
by strict dietetic and hygienic measures ; and there seems little 
doubt that mild local treatment is sometimes of great value. 
Occasions arise when mechanical measures are necessary to save 
the patient. 

The one mode of treatment which is indicated in all cases, 
but especially in the severe forms, is systematic feeding. Upon 
this, in a large number of instances, depends the ultimate result. 
The food should be easily assimilable, so that it will require 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 225 

little digestive action, and yet be nutritious. The second great 
desideratum is the regularity with which nourishment is taken, 
night as well as day ; in fact, it is often more important to insist 
upon this regularity at night than by day, as during the former 
period the debilitated system requires more to sustain it. Owing 
to a loss of appetite, it is not always possible to induce patients 
to take nourishment ; it may then become imperative to resort 
to some mode of artificial feeding, particularly rectal enemata. 
At times the pain is so great that the patient refuses to swallow ; 
it is then well to make an application of a 4-per-cent solution 
of cocaine or calendula preceding deglutition, that the inflamed 
areas may be rendered less sensitive. In other cases food is 
immediately ejected, when it will be necessary to advise some 
other form of nourishment, especially predigested meat-juice, 
bovinine, peptonized milk, matzoon, etc. Milk is praised by 
most physicians, but condemned by some, who either think it 
difficult to digest during diphtheria, or that its ingestion in- 
creases the pseudomembrane. A little lime-water or pepsin 
appears not only to render this most valuable food assimilable, 
but by its local action aids the solution of the false membrane. 
Ice-cream is often both acceptable and advantageous. Raw 
eggs are among the best forms of diet. Lemonade and lime- 
juice are frequently grateful. Finally, oily inunctions may be 
required. 

Although many advise the use of alcoholics, they do not 
seem to be of special advantage in the majority of cases. Their 
seeming efficacy in " tiding " the patient over a period of col- 
lapse or heart-failure may be counter-balanced by a pernicious 
secondary effect upon the heart. If, however, alcoholics, pref- 
erably brandy, be used, the special indications are irregular, 
flagging pulse (heart-failure), and syncope. 

When indications of heart-failure appear, it is important 
that the patient's head be low, and that he make little or no 
voluntary exertion. This precaution will sometimes prevent a 
fatal syncope. 



226 DISEASES OF THE NOSE AND THROAT. 

The local treatment has varied so much that it is not 
necessary to follow its history, but those remedies and means 
will be given which seem to harmonize with the use of the in- 
ternal drugs and lead to the comfort and improvement of the 
sufferer. These adjuvants are employed for the purpose of 
limiting the formation of the membrane, of dissolving' that which 
already exists, of acting as disinfectants, and of affording relief 
to the obstruction to respiration and deglutition. One point 
favoring the use of local measures is the belief that the bacilli 
are present only in the most superficial part of the membrane. 
The only excuse for forcibly dislodging the false lining is in 
those cases where the deposit impedes respiration, or where so 
gangrenous as to prove an undoubted source of auto-infection. 
When the membrane extends to the larynx or trachea, mechan- 
ical treatment will often be required. Different means may be 
tried as solvents of the membrane. Of these the most valuable 
are : lime-water (locally and internally), saccharate of lime 
(Lanne), lactic acid (30- to 50-per-cent aqueous solution), tryp- 
sin (pure or diluted with 20 per cent of bicarbonate of soda), 
papayotin (pure or dissolved in water), and pepsin and sugar of 
milk (in equal parts). The powders are to be insufflated and the 
solutions either sprayed or painted upon the false membrane 
every hour or two. 

Dr. A. Seibert, of New York, has made various favorable 
reports (the first, New York Medical Journal, December 6, 
1890) of his method of early submucous injections of chlorine- 
water (U. S. P.), " made directly through and under the diph- 
theritic pseudomembrane (submembranous) and into the in- 
flamed mucosa below." He uses a fine puncture syringe of 
special pattern. Two or three drops of 0.2-per-cent solution 
may be injected at two or three points. One injection usually 
suffices if used before the deposit becomes profuse ; otherwise, 
Seibert does not recommend the treatment. 

Alcohol as a gargle (1 to 4 or even 1 to 2) is a prepara- 
tion of great utility, and should be tried in all cases ; if used 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 227 

as a spray, 1 to 6 will be sufficiently strong. As antiseptics and 
disinfectants, permanganate of potassium (2 grains to the ounce 
of water), eucalyptus (20 per cent), and peroxide of hydrogen 
(25 per cent) act well. Liquor calcis chlorinati, as recommended 
by Dr. C. Neidhard, is of undoubted merit. This remedy and 
peroxide of hydrogen answer both as disinfectants and dissolv- 
ents. Some patients derive great satisfaction from the use of 
little pieces of ice held in the mouth ; others prefer inhalations 
of steam ; the latter not only relieve the dryness of the throat, 
but assist in loosening the membrane, when exfoliation has 
begun. When young patients will not inhale steam from the 
kettle or atomizer, it is advisable to moisten the atmosphere 
near the bed. Occasionally a tent may be needed ; this can be 
formed by throwing a sheet over a portion of the bed, or, more 
conveniently, over a crib ; the sheet should be kept some dis- 
tance above the child, either by the post or headboard of the 
crib, or a high-backed chair. Poultices and cold applications 
over the surface of the neck are doubtful aids. Lime may be 
used to great advantage when slacked in the room. The minute 
particles often give relief to pharyngeal irritation, and appear to 
have the power of dissolving or, more properly, loosening the 
false membrane. The best methods of generating steam are 
the steam-atomizer, the croup kettle, and hot water kept con- 
stantly boiling on a stove, or an alcohol or gas flame. As these 
are not always possible, the following device will answer : A 
bucket of cold water is placed in the room, into it a heated iron 
or brick is plunged and quickly removed ; in this way the room 
is soon filled with a moisture, both agreeable and beneficial. 

When the tonsils are so large as to greatly hinder respira- 
tion, they should be removed. Dr. Babchinski, of Kieff (London 
Lancet, April 26, 1890), has treated a number of cases by inoc- 
ulation of Fehleisen's coccus of erysipelas. The inoculation was 
performed by means of punctures in the submaxillary region. 
Of the fourteen cases so treated, two died before the erysipelas 
developed, the rest recovered, as well as those which developed 



228 



DISEASES OF THE NOSE AND THROAT. 



erysipelas spontaneously. Yet Roux and Yersin have noted a 
pseudo-bacillus very like that of the Klebs-Lcefner, but with- 
out virulence unless associated with Fehleisen's coccus. In 
1880, Dr. G. J. W. Kirk, then of Bristol, Pa., was successfully 
treating malignant diphtheria with hypodermic injections of 
permanganate of potassium, 2 grains to the ounce of warm 
water, in addition to the internal use of the drug. When 




Fig. 65.— O'Dwyek's Intubation Apparatus. 



the membrane appears in the nose, the treatment enumerated 
under " Primary Diphtheria of the Nose " should be employed. 
When the pseudomembrane extends from the pharynx to 
the larynx the affection becomes grave, and in the majority of 
instances some operative procedure will be required in order to 
relieve laryngeal stenosis. Retrocession of the supra-sternal 
notch and chest-walls and slight cyanosis are indications for 
tracheotomy or intubation, and, as a rule, the sooner it is done the 
better ; yet some cases recover, after the onset of these symptoms, 
without such interference. Where cyanosis is marked, however, 



DIPHTHERIA OF THE PHARYNX AND LARYNX. 229 

one or the other operation is urgent, unless the lungs be much 
involved from extension of the membrane, pulmonary collapse, 
or pneumonia. In these latter cases mechanical measures not 
only fail to relieve, but sometimes even aggravate the symptoms. 
If laryngeal dyspnoea be very marked and but little hope can 
be extended, operation is often advisable, even though its only 
prospect is to favor euthanasia. 

I cannot subscribe to the advice given by many surgeons, 
to operate as soon as false membrane appears in the larynx ; I 
have seen such cases recover without operation. 

In the light of recent statistics, it seems to make little dif- 
ference whether the trachea be opened or a tube be inserted 
through the natural passage ; on that account the choice of the 
operation usually devolves upon other points to be considered. 
After deciding upon the necessity for operation, the consent of 
parents, guardians, or friends must be obtained. Tracheotomy 
is considered by them a serious operation, and one upon which 
they often look with disfavor ; while intubation is scarcely an 
operation, as no cutting is done and no blood is lost. The 
choice is then but a natural one, even when they are told that 
"there are very occasional instances in which a hasty trache- 
otomy is required, when the membrane is pushed loose in front 
of the tube and obstructs respiration." This predicament, 
though, must be very rare ; I have never met such a case, 
although I always have the tracheotomy instruments in readi- 
ness. In some rare cases it may be necessary to open the 
trachea, where after a day or two the intubation-tube fails to 
give free respiration. Care should be taken not to overfill the 
stomach with fluid, lest the heart be mechanically interfered 
with. When the tonsils are very large they may greatly hinder, 
or even prevent, the introduction of an O'Dwyer tube, thus 
necessitating tracheotomy or previous tonsillotomy. 

Dr. Betz (CentraTb. f. die ges. Titer.) has succeeded in 
averting death, where an operation seemed inevitable, by having 
the patient inhale three or four drops of the following solution 



230 DISEASES OF THE NOSE AND THROAT. 

every half-hour : Sulphuric ether, 3 parts ; acetic ether and 
menthol, each, 1 part. Dr. Hirsch, of Prague {Pop. Horn. 
Zeitschr.), has had like results from a plaster of resin of euphor- 
bium, spread upon waxed tafeta and placed over the neck ; and 
Schech has succeeded by removing the membrane from the 
larynx by endo-laryngeal manipulation. The inhalation of 
chlorine-gas has frequently caused the immediate expulsion of 
laryngeal and tracheal casts. 

During the entire course of the disease it is well to keep 
the patient as quiet as possible, lest overaction of the weakened 
heart occur, and result in sudden syncope or heart-failure. The 
pulse should be carefully watched, and if it be very weak, irreg- 
ular, or fluttering, food should be given regularly and often ; and 
the extremities warmed with bags or bottles of hot water, hot 
bricks, stove-lids, or friction. Brandy may be administered. The 
head should be lowered, and cactus grand., cocaine, or digitalis 
given internally. As the patient improves, the greatest caution 
should be exercised to continue the recumbent posture, even 
after the acute symptoms are apparently relieved, lest heart- 
failure suddenly terminate an otherwise favorable case. 

Internal remedies are of the utmost importance, but space 
forbids reference to all thus indicated, or used. An effort will 
be made, however, to give a practical resume of this division of 
the subject. 

Prophylactics are of such value that they should always be 
employed, giving semi-daily doses to those who are exposed. 
Apis has the greatest reputation as a preventive, but it is better, 
usually, to give the remedy which seems to be best adapted to 
the special epidemic, or, if sporadic, to the case or cases treated. 

The?*apeutics. 

Ailanthus. — Great stupor ; nasal discharge makes the upper 
lip sore ; throat and tonsils livid, swelled, and deeply ulcerated. 
Torpor and stupor. 

Ammon. carb. — When the membrane is chiefly confined to 



THERAPEUTICS OF DIPHTHERIA OF THE PHARYNX AND LARYNX. 231 

the nose, with an extension to the lips ; the pharynx is almost 
free, but often gangrenous ; great prostration. 

Apis. — Prophylactic. Patches first appear on the uvula 
and faucial arches ; much swelling ; oedema of the face and 
neck ; deglutition very painful ; scanty urine ; prostration from 
the start ; not much fever ; pulse rapid, but not strong. Throat 
bright-red and as though coated with red varnish. Membrane 
dirty gray, thick like chamois-skin, worse on the right tonsil, 
which is often studded with deep, gray, angry-looking ulcers. 
Uvula cedematous, interfering with deglutition. Glottis en- 
croached upon by oedema and swelling, producing dyspnoea ; 
some rash; much swelling of cellular tissue outside and in, 
with erysipelatous appearance, but without abscess formation. 
I look upon apis as one of the most useful remedies for diph- 
theria. 

Ars. alb. — Advanced sepsis ; membrane dark, dry-looking, 
and wrinkled ; great fcetor ; internal and external swelling ; 
nasal discharge thin and excoriating; oedema of the throat, 
great pain ; prostration ; albuminuria. 

Arum tri. — Discharge from the nose and throat very acrid 
and excoriating ; lips sore and swelled ; throat burns ; deposit 
in the larynx. Dr. A. Korndoerfer says it has less bleeding 
from the nose than has nitr. acid, less soreness, lips less black, 
less rash on the body, and it has more hoarseness, restlessness, 
and tossing about. 

Bap. — Prostration intense; half stupid, almost besotted look; 
typhoid condition. Absence of pain ; gangrenous odor from the 
nose and mouth ; pseudomembrane is dark and has a tendency 
to become gangrenous ; oedema of the fauces and uvula. 

Bell. — Much dryness and severe dysphagia from the begin- 
ning ; glands swelled ; neck stiff. Throat bright-red ; fever 
high. Bell, and mere, cyan., in alternation, are lauded by Marc 
Jousset for diphtheritic croup. 

Canth. — Post-diphtheritic albuminuria, the urine contains 
tube-casts ; extreme prostration ; attacks of syncope. Dr. Neid- 



232 DISEASES OF THE NOSE AND THROAT. 

hard, in writing of the laryngeal involvement ("Diphtheria," p. 
153), states: " From seventy to eighty cases of the mild as well as 
the most aggravated form were treated by me with cantharides 
in the first and second dilutions, with decided benefit. The 
disease seemed to be arrested by this remedy, although rather 
slowly." Severe burning pains with rawness and constriction 
of the throat and larynx, sometimes almost amounting to suffo- 
cation on attempting to swallow water. Marked debility. 

Carbol. ac. — "No high local inflammation; no severe pain. 
Great accumulation of deposits, spreading a most offensive 
odor. Grayish, bluish membranes, with a tendency to putre- 
faction; with a cadaveric stink and swelling of the cervical 
glands. Exudation extending into the larynx." (A. McNeil, 
"A Treatise on Diphtheria.") 

Caust., curare, gels., oleander. — Post-diphtheritic paralysis. 

Cocaine 1 x and kali cyan. 3 x are recommended by Dr. 
\V. C. Goodno for a pulse which is rapid, feeble, and perhaps 
rhythmically disturbed ; impending heart-failure. 

Crotalus. — Especially for the persistent epistaxis : general 
grave blood-poison and great prostration. 

Helonias. — For the prostration — broken-down condition — 
which remains for weeks after the cure seems otherwise com- 
plete. A condition amounting almost to chlorosis in some 
cases. 

Ignatia. — Much swelling of the anterior cervical glands ; 
delirious sleep, crying out for help ; stitches from the throat to 
the ears. Ignatia was first advised by Dr. Boskowitz, of 
Brooklyn, and since used by many practitioners almost empir- 
ically, but with good results in many instances. My first 
acquaintance witli this remedy and this disease was during my 
early study with Dr. George J. W. Kirk, who was then using 
ign. in alternation with apis, with very gratifying results, as he 
scarcely lost a case in an epidemic which proved generally fatal 
among the patients treated by other physicians. 

Kali bi. — Worse after sleep (lach.) ; tough, ropy, yellow, 






THERAPEUTICS OF DIPHTHERIA OF THE PHARYNX AND LARYNX. 233 

discolored, bloody mucus ; pharynx, fauces, and even hard pal- 
ate covered with a grayish-yellow exudate ; uncovered portions 
purple ; deep ulcers of the fauces ; nose and larynx invaded ; 
marked glandular involvement, nervous prostration. 

Kali permang. — Swelling within and without ; oedema of 
the soft palate and uvula ; thin, sanious, nasal discharge ; exco- 
riating upper lip ; horribly offensive odor. Black, gangrenous 
exudate ; great prostration. Dr. I. W. Hey singer (Jotir. Ojrfi., 
Otol, and Lar., January, 1892) highly recommends 1 grain of 
the crystals in about 3 ounces of pure water. One teaspoonful 
is given, alternately with mother-tincture of bell., every hour or 
less. He also uses the permanganate of potassium as a prophy- 
lactic. Dr. W. B. Van Lennep considers it "almost a specific," 
and I have had very gratifying results from its use. 

Kali phos. — " In the well-marked malignant, gangrenous 
condition ; patient exhausted, prostrated. Also for the after- 
effects of diphtheria, such as weakness of sight, nasal speech, 
or paralysis in any part of the body, squinting, etc. The 'putrid 
character is well marked, as seen by the bone and putrid- 
smelling odor from mouth." (Boericke and Dewey's " Tissue 
Remedies.") 

Lac can. — This remedy has been used to a limited extent, 
but with apparently good results in many instances. Great 
restlessness, turning and shifting; throat feels dry, husky, as 
if scalded. According to the late Dr. Lippe, ulcers go from 
side to side and have a glistening, shining appearance ; the 
glands swell, are painful to touch, and have the same change- 
able character ; the nasal discharge excoriates the nostrils and 
upper lip. Diphtheria beginning in the larynx and passing 
upward ; partial suppression of urine ; oedema of pharynx. 

Lach. — Asthenia throughout; the false membrane goes 
from left to right ; neck stiff and tender to contact ; worse after 
sleep; hoarseness; nasal discharge thin, sanious, excoriating; 
neck very sensitive to contact; subjective symptoms more pro- 
nounced than the objective ; deep redness of mucous membrane; 



234 DISEASES OF THE NOSE AND THROAT. 

a tendency to attack the larynx ; swelling of the glands and 
cellular tissue, in which suppuration may occur ; urine scanty 
and albuminous ; offensive diarrhoea. The patient drowsy, the 
extremities cool, and the pulse feeble. 

Liquor calcis chlorinate. — Dr. C. Neidhard recommends 
from 5 to 15 drops in J tumblerful of water, a teaspoonful, 
according to urgency of the symptoms, at intervals of from one- 
fourth hour to six hours; alone, or in alternation with other reme- 
dies. On the 17th of September, 1891, the doctor said to me: 
" There are many very valuable remedies for the treatment of 
diphtheria, but I have found none so prompt or so efficient as 
the liquor calcis chlorinatae." In a number of instances the 
remedy has served very faithfully. Bell, acts as its antidote. 

Merc. cor. — According to the late Dr. J. G. Houard, it is 
especially useful if there be nasal haemorrhage ; great prostra- 
tion ; offensive and dark or yellowish-white false membrane on 
the nasal passages and pharynx ; ulcers on the inside of the 
cheeks ; salivation, and secondary stomach trouble. 

Merc. cyan, has great prostration as its chief character- 
istic ; laryngeal involvement and marked swelling of the glands. 
Stringy, thick expectoration (kali bi. has less prostration). 
Dr. von Villers gives the following indications: "An exudate 
which may be white, yellow, gray, or of an intervening shade ; 
adynamic fever and collapse even at the commencement. The 
pseudomembrane, owing to its situation, may not be visible." 

Merc. dulc. — If there be grass-green and very offensive 
diarrhoea this remedy is strongly indicated and should be given 
at once. This and kali bi. are Dr. Isaac G. Smedley's favorites. 

Mur. ac. — Intense prostration ; mucous membrane of the 
mouth and throat denuded and dark red or bluish red ; the 
ulcers in the mouth are black or have a dark base, with a ten- 
dency to perforate ; yellowish -gray deposit and fetid odor. 
(Edema of the uvula (ars., caps., hydroc. ac, kali per., mere, 
cyan., natr. ars.). Acrid nasal discharge, excoriating nostrils 
and upper lip ; epistaxis of dark blood ; drowsy, stupid, typhoid 
condition. 



THERAPEUTICS OF DIPHTHERIA OF THE PHARYNX AND LARYNX. 235 

Naja tri. — " In impending paralysis of the heart. The 
patient is blue. He awakens from sleep gasping. The pulse 
intermittent and thready." (Farrington.) (Compare cocaine.) 
The cough is deep and hoarse ; dyspnoea ; retention of urine. 

Pine-apple juice has found much favor with the laity. 

Rhus tox. — Pseudomembrane dark and bloody; saliva 
(sometimes bloody) flows from the mouth during sleeps Gland- 
ular and cellular involvement, with pus formation in some 
cases. Restless ; the child wants to be carried about. Post- 
diphtheritic paralysis. 

Sulph. has been used most frequently, especially by the 
laity, as an insufflation of the powder made from the flowers. 
It acts favorably in some instances, but the claim of its specific 
nature has brought disrepute upon it. Internally, it is indicated 
for a false membrane confined to the pharynx, not attacking the 
fauces or tonsils, which are dark red and painful ; slowly pro- 
gressing cases in psoric persons. 

Sulph. ac. — When there is a large amount of thick, gray, 
or yellowish discharge. Deathly pallor of the surface; drowsy; 
somnolence. This is one of the best local applications or gar- 
gles, using a 2 x alcoholic preparation diluted with an equal 
quantity of water. 

Tarentula. — Dr. Samuel Freedley compared it to the action 
of aeon, in acute inflammatory fevers ; and added : " Tarentula 
cubensis, I have found, will cure diphtheritic fever in its highest 
forms with delirium, in about the same time that the former 
remedy cures acute fever, and if given at the proper time rarely 
wants any other medicine to perfect the cure." W. J. Martin 
{Trans. Horn. Med. Soc. of Pa., 1884) made the preceding quo- 
tation, followed by the histories of a number of cases cured by 
the remedy in the 3 x dilution in water. It seemed to have no 
important influence when the larynx was involved, but fre- 
quently acted in promptly reducing the fever and curing the 
patient. In concluding his paper, Dr. Martin says: "If you 
get a case where none of the old and oft-tried remedies are 



236 DISEASES OF THE NOSE AND THROAT. 

indicated, where it seems as though the symptoms call for bell, 
and mercury both at the same time, there you have a case for 
tarentula ; and I do believe, as a rule, if we get the case within 
about twelve hours of its start, we can check the progress of 
the disease at once." 

Terebinth-oil. — When a croupy cough or husky voice de- 
notes the involvement of the larynx, a drink of milk, immediately 
followed by a teaspoonful of spirits of turpentine or of tar, 
sometimes proves prompt and pleasing. This remedy is often 
used as a prophylactic, and for the prostration and lack of ap- 
petite following the attack. Its inhalation in the form of vapor 
often adds greatly to the comfort of the patient. 

Zinc. — Dr. Woodward {Medical Era, March, 1890) writes : 
" In diphtheritis where there seemed no hope, I have found zinc 
to act like magic. It is indicated when the disease, starting in 
the pharynx, goes down to the larynx, with much infiltration of 
glands ; great pallor, with very feeble and irregular pulse, hands 
and feet cold; and, still more definitely indicated if, in addition, 
there is delirium or coma, with severe prostration." 



CHAPTER XVIII. 

Various Conditions. 



HAEMORRHAGES OF THE PHARYNX. 

Etiology. — In a mild degree, hgemorrhage of the pharynx 
is quite frequent, but severe bleeding is rare. The former is 
usually the result of coughing, gagging, retching, vomiting, or 
ulceration ; the latter, of injury to a blood-vessel, severe ulcera- 
tion, new growths, gangrene, or cancer, when it may prove dan- 
gerous or even fatal. Vicarious haemorrhage of the pharynx is 
infrequent. 

Symptoms. — In the mild form, the bleeding is usually capil- 
lary and has generally ceased when the patient is seen ; if not, it 
is probably noticed to trickle from the naso-pharynx (often epis- 
taxis), although it may be from the pharynx itself. The soft 
palate and uvula are sometimes the seat of a submucous haemor- 
rhage, when they usually present the appearance of a sheet of 
blood ; but in rare instances they are dotted with numerous 
bright-red spots. 

The retropharyngeal tissues may be the seat of a profuse 
bleeding (hsematoma), the accumulation giving rise to symptoms 
not unlike those of retropharyngeal abscess. In one case 
operated by Stoerk, bright-red blood spurted out, giving the 
idea that he had opened an aneurism. 

Prognosis. — The prognosis is good in most cases, but it is 
not always possible either to arrest the bleeding or to prevent 
the resultant gangrene. 

Treatment. — If slight bleeding persist after the patient is 
seen, aeon., hamamel., lach., phos., etc., may immediately con- 
trol it ; but it is usually well to prescribe a gargle of gallic acid, 
tannin, alum, or some other astringent. If, in a reasonable time, 
the preceding treatment fail to relieve the bleeding, digital com- 

" (237) 



238 DISEASES OF THE NOSE AND THROAT. 

pression should be used. In profuse haemorrhage, if the bleed- 
ing-point be found, it should be grasped with tenaculum or 
forceps and twisted or compressed : usually, however, it is easier 
to touch the point of bleeding with chromic acid or the galvano- 
cautery. If the carotid be injured, its main trunk must be 
ligated, as compression is rarely effectual. If the soft palate be 
infiltrated, little treatment is usually required, unless the mucous 
lining seem to be stripped from the underlying structures, when 
the former should be punctured. If the uvula be very much 
infiltrated it is best to incise it, either with a pair of scissors 
or a sharp-pointed knife ; care should be exercised not to injure 
the half-arches or posterior wall of the pharynx. When the 
tonsils, arches, or peritonsillar tissues are involved, gangrene 
may follow, and in the great effort to swallow the tissue may be 
torn in shreds or the deeper parts completely denuded. 

After the cessation of any haemorrhage, the patient should 
be careful in swallowing hard or sharp food, lest the bleeding 
recur ; and after a considerable loss of blood the patient should 
be kept quiet in the recumbent posture and given china. 

If a hsematoma exist, it should be treated as similar 
extravasations elsewhere. 

For therapeutics, see " Epistaxis." 

RHEUMATIC AND GOUTY PHARYNGITIS. 

Etiology. — These diseases are not only associated with the 
same affections occurring elsewhere, but they often alternate 
with them. The local pharyngeal manifestations are not often 
characteristic, but show themselves in severe pain or aching in 
the throat, and sometimes in acute inflammation. 

Symptoms. — The attack is usually precipitated by exposure 
to cold, gastric irritation, or metastasis. Acute pain soon fol- 
lows, accompanied by difficult and painful deglutition. There 
may be no change in the appearance of the throat, but there is 
often some redness of the soft palate or pharynx ; the uvula may 
be ©edematous. The pains may come and go several times during 



THROAT AFFECTIONS OF THE EXANTHEMATA. 239 

the attack, they may alternate with more general symptoms, or 
they may precede a general attack. The duration is short, — 
from one to three or four days. 

Diagnosis. — The diagnosis depends upon the collateral 
symptoms, and must be distinguished from neuralgia, enlarged 
lingual glands or veins, chronic follicular tonsillitis, glossitis, 
tobacco-throat, cancer, and from a similar throat trouble in 
lithaemic patients. The changes in the last-named trouble are 
thus described by A. W. Hinkle : '•' There is a patchy conges- 
tion of the laryngeal face of the epiglottis, extending along the 
ary-epiglottic folds and over the posterior aspect of the ventricu- 
lar bands ; this same patchy condition may exist in the pharynx, 
extending in streaks along the postero-lateral walls, with a 
sense of uneasiness or pain on swallowing. The pain darts 
into one or both ears, and seems to come out of the ear. There 
is a harsh, dry cough, with a sense of extreme irritation about 
the larynx. One point in the diagnosis is the extreme sensitive- 
ness of the affected parts to astringent and stimulant applica- 
tions, which likewise aggravate." 

The internal use of colch., natr. sal., or rhus tox. will 
relieve most cases promptly. 

THROAT AFFECTIONS OF THE EXANTHEMATA. 

Measles. — This is chiefly a catarrhal process contempora- 
neous with a similar affection of the nose, Eustachian tubes, 
ears, and eyes. Sometimes small, dark-red patches occur on the 
pharynx, palate, or tonsils, even before the appearance of a 
cutaneous invasion. The pharynx may appear livid or even 
membranous, in severe or malignant cases. 

Small-pox. — The chief appearance is that of pustules in 
the mouth and pharynx, similar to those seen upon the surface, 
and which they may precede. Between the pustules the mucous 
membrane is decidedly inflamed ; or there may be inflammation 
without pustule formation. The secretion is usually very pro- 
fuse and viscid. Dysphagia is severe, especially after rupture 



240 DISEASES OF THE NOSE AND THROAT. 

of the pustules. The larynx may become (Edematous, and the 
naso-pharynx may inflame, swell, ulcerate, and be covered by a 
layer of pseudomembrane. The diagnosis depends upon the 
cutaneous affection or the prevalence of small-pox. The throat 
complication usually appears from the fifth to the seventh day 
of the attack. 

Scarlet Fever. — The throat usually becomes vividly red, 
hot, and tender soon after the appearance of the rigors and the 
pyrexia. The tonsils swell at an early date and exude a tena- 
cious mucus, which may, later, form a pseudomembrane, in 
which process the fauces may partake ; thus simulating diph- 
theria, from which it is sometimes difficult to distinguish (see 
" Diphtheria of the Pharynx and Larynx"). After separation 
of the false membrane, ulcers, often quite large and deep, exist 
for a time ; they are especially pronounced upon the tonsils. 
Gangrene is a rare complication. The nose and pharynx 
usually suffer, and the ears and larynx are not always exempt. 

TUBERCULOSIS (PHTHISIS) OF THE PHARYNX. 

Although it is possible to have a primary phthisical pharyn- 
gitis, the condition is usually secondary to tubercular changes 
in the lungs or larynx. It may show itself in grayish, shallow, 
lenticular ulcerations or granulations distributed over the 
pharynx, faucial region, and palate; or in a deposit of miliary 
tubercles, which may degenerate, if the patient survive so long. 
The usual manifestations are reflex, if such a term may be 
used ; that is, the phthisical condition existing elsewhere shows 
itself in the pharynx in the form of a partial anaemia. By 
this is meant that anaemia in which the greater part of the soft 
palate is pale, but at the same time there are spots of congestion 
over the surface of which run dilated vessels. I have already 
referred to this condition {Trans. Horn. Med. Soc. State of Pa., 
1883) as anaemio-hyperaemia of the pharynx, characteristic of 
the early stage of phthisis. In addition to this, there is often 
a tremulousness of the soft palate and uvula and a very spacious 



TUBERCULOSIS (PHTHISIS) OF THE PHARYNX. 241 

pharynx, the soft palate and uvula seeming to be very thin and 
well thrown forward (see " Phthisis of the Larynx "). 

Etiology. — The causes of phthisis of the pharynx do not 
seem to differ from those which induce the disease elsewhere, 
except that a catarrhal or other affection of the pharynx seems 
to act as an exciting cause. 

Pathology. — The pathological changes are similar to those 
occurring in phthisis elsewhere. In phthisis florida there is 
acute miliary tuberculosis of other organs as well. In the more 
chronic form there is a deposit of tubercles in which tubercle 
bacilli may often be discovered ; or, still others in which tuber- 
cles do not complicate the waste of tissue. 

Symptoms. — The symptom of the acute form which may 
first attract attention is the functional loss of voice ; but Sticker, 
of Munich, calls attention to a bright-red line of demarcation 
between the teeth and the tongue as an early symptom. It is 
bright-red in acute and bluish in chronic phthisis, and white in 
pronounced scrofula. If there be a deposit of miliary tubercles 
the same general symptoms exist as in acute miliary tuberculosis 
of other organs, in addition to which are burning and smarting 
in the throat and ears and extreme painfulness on deglutition. 
The pharynx, soft palate, and appendages are often congested ; 
occasionally they are studded with minute elevations, perhaps 
enlarged follicles or tubercles; or a grayish, lenticular-shaped, 
superficial ulceration may appear and extend to the post-nasal 
region or to the larynx. There seems to be no disposition for 
the ulceration to extend to the deeper parts, not even between 
the muscular fibres, but the ulcers usually become confluent and 
are transformed into cheesy, pus-covered nodules. The temper- 
ature often rises to 104° or 105° F., the pulse frequently to 140 
or over, the cervical glands swell, and the face shows the pecu- 
liar phthisical cachexia. With all of these the appetite is fre- 
quently good, the bowels regular, and the functions apparently 
normal. Death usually occurs from three to ten weeks after 
the apparent onset. 



242 DISEASES OF THE NOSE AND THROAT. 

Prognosis. — The prognosis is unfavorable in all cases of 
acute pharyngeal phthisis, and when the stage of ulceration is 
established the patient usually soon succumbs to the disease ; 
if the tongue be ulcerated, secondarily, the patient often dies 
suddenly. 

If the pharyngeal affection be secondary to pulmonary 
phthisis the condition may be similar to the foregoing, but the 
fatal termination is delayed for from three months to two years. 
Recorded cases of undoubted cures are more numerous than 
formerly. In this form the ulcerative process usually follows 
the deposit of tuberculous material. The characteristics are : 
rather slow ulceration, with severe pain ; worm-eaten ulcers, 
with faint hyperaemic areola? and slightly elevated and gradually 
receding edges ; the surrounding mucous membrane is often 
studded with small, pale nodules, which doubtless nourish the 
ulcerative process ; and the base of the ulcer is covered with 
yellowish, glutinous, muco-purulent debris. There is little 
granulation structure and, usually, no tendency to heal. The 
breath is, generally, very offensive. When the stage of ulceration 
supervenes, the fever and pulse range high, the appetite is soon 
affected, and deglutition rendered impossible owing to pain and 
to the passage of food through the nose or into the larynx. 
Sometimes the tongue is ulcerated before the pharynx, or the 
former alone may be attacked. Ulcers of the tongue are gen- 
erally clean, very sluggish, and irregularly oval, with deep or 
overhanging edges and a yellowish-white base. The patient 
rarely complains of pain in the tongue, and is often unaware of 
the presence of the ulcer. The cases that have come under 
my notice have died within six weeks, usually quite suddenly, 
and with little warning of immediate danger. 

Diagnosis. — It is not always easy to discriminate between 
phthisical, syphilitic, and scrofulous ulceration of the pharynx, 
but the following points will serve as guides: In phthisis there are 
usually high fever, rapid pulse, emaciation, cough, profuse puru- 
lent expectoration, and severe pain. In syphilis there are, occa- 



TUBERCULOSIS (PHTHISIS) .OF THE PHARYNX. 243 

sionally, moderate emaciation and slight cough, attended by a 
watery, gluey, or ropy secretion ; there is rarely pain, except occa- 
sionally during deglutition, when it may be very severe. In 
scrofula there is little pain ; constitutional symptoms are almost 
wanting, save those referable to the strumous diathesis ; and 
there may be cough and yellow expectoration. In phthisis the 
anterior cervical, the submaxillary, and the parotid glands may 
be swelled and tender ; in syphilis, the posterior cervical ; in 
scrofula, both, but especially the anterior. In phthisis the 
ulcers are not visibly excavated, they appear to increase by 
lateral invasion, their edges are irregular, the line of demarcation 
is indistinct with a faint areola, the granulations are indolent, 
and there is little tendency to heal. In syphilis the ulcers are 
deep, extend by attacking the deeper tissues; their edges are 
sharply cut, the line of demarcation distinct ; there is a deep-red 
areola, and the granulations are active with a decided tendency 
to heal. In scrofula the ulcers are excavated and sluggish in 
healing. If the tubercule bacilli be present, the diagnosis is 
certain. 

Treatment. — In the management of these cases the diet 
should be carefully regulated, and only such articles given as 
will prove soothing to the diseased parts. The food is more 
easily taken if only moderately warm and semi-solid. Gruels, 
broths, soups, raw eggs, raw oysters, jellies, custards, corn-starch, 
and Irish moss are usually grateful and nutritious. It may be 
necessary to feed the patient with the oesophageal tube passed 
gently into the upper portion of the oesophagus, or, if this be 
impossible, by rectal alimentation or inunction of oils and fats. 
The various malt preparations and the hypophosphites of lime 
and soda are of great utility. If local treatment be required, 
the ulcers should be cleansed and dusted with powdered iodol 
or boric acid, or sprayed with a 40-per-cent solution of lactic acid, 
a 15-per-cent solution of peroxide of hydrogen, a 20-per-cent 
solution of calendula, or a 10-per-cent solution of resorcin or 
menthol. If the dysphagia be so severe as to impair nutrition, 



244 DISEASES OF THE NOSE AND THROAT. 

the ulcer should be sprayed with a 2-per-cent solution of hydro- 
chlorate of cocaine or the calendula solution, fifteen minutes be- 
fore each meal. The powders named sometimes appear to arrest 
the ulcerative process, but lactic acid and peroxide of hydrogen 
are the most efficient local adjuvants. Morphine is rarely 
necessary, if the remedies be selected with care ; but should the 
latter fail to relieve the pain, and cocaine and calendula be used 
without effect, T \ grain of acetate of morphine may be mixed 
with 3 grains of powdered starch and either dusted or insufflated 
upon the ulcer, about thirty minutes before a meal. Curette- 
ment of the ulcer, as in laryngeal phthisis, is a rational measure. 
Hygiene, diet, change of air, and exercise are to be carefully 
considered. 

For therapeutics, see " Phthisis of the Larynx." 



CHAPTER XIX. 

Syphilis, Scrofula, Lupus, Leprosy. 



SYPHILIS OF THE PHARYNX. 

Syphilis usually appears as a secondary or tertiary pharyn- 
geal disorder, less frequently as an inheritance, and exceptionally 
as a primary disease of, generally, the right tonsil. Compara- 
tively few persons pass through the second and third stages 
without some pharyngeal implication ; for example, mucous 
patch, gumma, ulcer, periostitis with exfoliation of portions of 
the cervical vertebrae or hard palate, relaxation and congestion 
of a dusky hue (erythema), swelling, oedema, or excoriation. 

The secondary form usually appears about one year, often 
less, after the inception of the chancre, and manifests itself in 
the form of erosions of the mucous membrane ; papules ; broad 
condylomata ; symmetrical, dusky-red, congestive patches ; sub- 
mucous infiltration ; mucous tubercles ; and mucous patches.. 
The tonsils, pillars of the fauces, buccal cavity, and tongue are 
usually attacked, in frequency, in the order named ; the pos- 
terior pharyngeal wall generally escapes. Cloudy epithelium 
must be looked upon with suspicion. 

Symptoms. — Symptomatically, syphilis is usually well dif- 
ferentiated from other diseases by its history and objective ap- 
pearances. The chief subjective symptoms are stringy and 
gluey discharge, fullness in the pharynx, inability to swallow 
with comfort, loss of taste or smell, and usually absence of pain 
except during functional activity. If relaxation and congestion 
alone be present, a dryness or slight rawness may be the only 
symptom. Objectively, thick, nasal intonation is to be noted. 

If erythema alone be present, inspection does not always com- 
plete the diagnosis; but if the membrane be slightly irritated 
with a smooth probe, the specific dusky, mottled appearance 

(245) 



246 DISEASES OF THE NOSE AND THROAT. 

often prominently manifests itself. When, in addition, it is pos- 
sible to get some general history of syphilis, either from the 
patient's admission or from some cutaneous or other manifesta- 
tion, the diagnosis may be made fairly sure. One of the char- 
acteristics of secondary syphilis of the pharynx is its symmetri- 
cal, bilateral arrangement, the sides frequently appearing quite 
similar. The ulcers are often kidney-shaped, grayish white, 
and, as suggested by Procter S. Hutchinson (" Diseases of the 
Nose and Throat "), they have " the appearance of snail-tracks 
on the tonsils." When the mucous patch occurs on the lips, 
tongue, soft palate, or pharynx, its circular form, slight eleva- 
tion, and glazed, bluish-white color will at once render positive 
the nature of the disease. 

Prognosis. — The prognosis of the secondary form is usually 
good, although a chronic pharyngeal catarrh may be induced, 
•or the larynx secondarily affected with a persistent inflamma- 
tion. 

The tertiary stage of pharyngeal syphilis occurs at any 
time from two to forty years after the primary sore ; the usual 
period, however, being from two to five years. Although the 
erythema, the mucous patch, and the slight abrasion are charac- 
teristically found in the second stage, patches are not rare in the 
tertiary form, and it is in this stage that gummata (syphilitic 
nodes, syphilomata) occur and deep and phagedenic ulcers 
appear. 

Symptoms. — The symptoms are similar to those of secondary 
syphilis, with these additions : regurgitation of food through the 
nose, if there be much ulceration of the soft palate, uvula, and 
pharynx and thick, profuse, stringy, muco-purulent, or bloody 
discharge, often containing necrotic tissue. Nasal and pharyn- 
geal respirations are hindered if there be great swelling or oedema 
of the tissues. Inspection usually clears up the diagnosis at 
once, if the disease be of a severe nature. The starting-point 
of the deep ulcer is generally a gummatous growth which, 
undergoing the process of destruction, ends in the ulcer which 



SYPHILIS OF THE PHARYNX. 247 

rarely extends beyond the original borders of the gumma, but 
is usually quite deep. When not the result of a gumma, the 
tissue loss may extend in all directions, and, owing to its char- 
acter, perforate the hard palate and destroy large areas of the 
mucous, submucous, muscular, glandular, or other tissue. 
Syphilitic papules, condylomata, and other elevations generally 
heal with subsidence of the destructive process. 

Ulceration usually appears on the pillars of the fauces, soft 
palate, uvula, and tonsils, in the order named. When the soft 
palate is attacked, it is generally in the median line. Some- 
times the first appearance is that of a boggy, dull-looking, oval, 
or circular spot, proving the existence of an ulceration nearly 
ready to perforate from the opposite surface, and which can 
sometimes be seen by the rhinoscopic mirror. The ulcers are 
always surrounded by a bright zone ; their edges are either 
smooth or ragged. After healing, the surface has a glazed, 
bluish-white, sclerosed appearance, with cicatricial distortions. 

Subjectively, there is often slight complaint, but pain is 
rather frequent where the Eustachian region is implicated, and 
food often regurgitates through the nose, especially when the 
uvula and soft palate are ulcerated, in which case there is nearly 
always a thick or " nasal " voice. When these regions are 
affected there is very generally a faintly cedematous appearance 
of the parts, apparently associated with some hypertrophy of 
the surrounding structures. The uvula and a large part of the 
soft palate may be destroyed, and extensive areas of the pharynx 
may suffer. Cicatricial contractions, adhesions, and distortions 
frequently result. 

Prognosis. — The prognosis is not usually grave, if the 
patient place himself under treatment before the ulcerative 
changes are well established. If, on the contrary, the processes 
of ulceration and necrosis have long existed, the loss of tissue 
is sometimes very great and interferes with deglutition, vocali- 
zation, respiration, and hearing, and, indirectly, the usefulness 
or even the life of the patient may be sacrificed. Deformity is 



248 DISEASES OF THE NOSE AND THROAT. 

not infrequent, owing to caries or necrosis of the bones of the 
palate and nose. The bands of cicatricial tissue which so often 
stretch from the soft palate to the posterior wall of the pharynx 
may impede respiration, vocalization, and deglutition. (Edema 
may so complicate pharyngeal syphilis as to result in severe 
stenosis. The larynx is occasionally implicated, but this usually 
occurs at a later date than does the pharyngeal disease. 

Treatment. — It must be borne in mind that syphilis of the 
pharynx is a local manifestation of a constitutional malady, and 
on that account its treatment should be chiefly constitutional ; 
at the same time, it is not well to neglect the local applications 
so useful in curbing, and later in healing, the destructive 
process. 

The employment of mineral caustics for the purpose of 
limiting the ulceration is not to be encouraged, as it is unneces- 
sarily severe and rarely serves the purpose intended ; but the 
galvano-cautery often answers well and is less painful. The 
following application has stood the test of long experience : 
iodine (metallic), gr. xv; alcohol, q. s. ; and glycerin, gj ; to be 
applied two or three times a day, after thorough cleansing with 
the spray, gargle, or post-nasal syringe. As a cleanser, a spray of 
a weak aqueous solution of permanganate of potassium or boric 
acid answers well. While the medicated application should 
not generally be used oftener than three times a day, the throat 
should be cleansed more frequently. In the hands of some, 
insufflated iodoform holds the first rank; but I have rarely seen 
it check the ulceration, and, as it is so unpleasant to the patient 
and his friends, iodol is to be preferred ; or, still better, pow- 
dered boric acid. Even though the tonsils be very large, it is 
better not to operate upon them during the active syphilitic 
invasion, as the raw surface often ulcerates. 

During the progress of syphilis it is important that alcohol 
in its various forms and all irritating food be discarded. If per- 
foration of the soft palate exist, food should be either solid or 
semi-solid, as liquids unthickened with corn-starch, arrowroot, 



THERAPEUTICS OF SYPHILIS OF THE PHARYNX. 249 

etc., are apt to pass into the nose. If deglutition cause pain, 
food should be very bland and soft. The hygiene of the patient 
should be guarded ; to this end plenty of fresh air, exercise, sleep, 
and good, non-irritating food are requisites. Frequent bathing 
is important, and the night and morning friction with a coarse 
towel, flesh-brush, or horse-hair gloves should not be neglected. 
The Turkish bath often proves an excellent adjunct to other 
treatment, and a course at a mineral spring aids materially. 
The patient should have one point indelibly fixed upon his 
mind, namely, that the treatment of syphilis must extend over 
a number of years. Finally, he must be impressed with the 
danger of transmitting the affection to others. 

In controlling the progress of the oedema and ulceration, 
nothing acts so well internally as kali iod., although some prefer 
sod. iod. To judge from clinical experience, kali iod. is best 
used in the crystals, or in the first decimal trituration ; in either 
event, it is advisable to dissolve two or three grains in a table- 
spoonful of water and order that amount to be taken three 
times daily. A decided improvement often follows the first 
few doses, but this relief frequently ceases after a couple of weeks, 
when, if other indications be absent, it is well to make use of 
mere. iod. ruber, 2 x or 3 x trituration. 

Therapeutics. 

Calc. fluor. — Ulceration of mouth and throat ; caries and 
necrosis, with burning, boring pains and thin, acrid, ichorous 
discharge. Congenital syphilis of infants. 

Fluor, ac. — Syphilitic ulceration of fauces, uvula, and 
tongue ; throat extremely sensitive to cold. Soft palate in- 
tensely red and tumefied. 

Kali bi. — Fauces dark-red or coppery. Deep ulceration with 
tendency to perforate, and with a coppery-red areola. Nasal 
bones affected ; soft or hard palate perforated ; ozaena ; hard, 
green lumps are expelled from the posterior nares. 

Kail iod. — Gumma; oedema; thin, excoriating discharge; 
deep ulcers ; and great distortion of tissue. 



250 DISEASES OF THE NOSE AND THROAT. 

Kali mup. — Ulceration, with red and tumid mucous mem- 
brane. I have recently used the chloride of potassium success- 
fully where before I had thought the iodide the only remedy 
for the case. 

Merc. cor. — Phagedenic ulcers of mouth and pharynx, 
foetid breath ; uvula ulcerated. 

Merc. cyan. — Ulceration of the centre of the palate, with 
hard, everted, irregular edges. 

Merc. dulc. — Ulcers flat and superficial; small, and due to 
bursting of vesicles. 

Merc. sol. — Painful tumefaction of the tongue; large, flat, 
pale ulcers, with dark-red areolae. 

Nitric ac. — After the abuse of mercury. Ulcers irregular in 
outline ; deep ; exuberant, easily bleeding granulations ; pains 
burning, sticking, like splinters; angles of mouth fissured. 

Phyto. — Secondary syphilitic ulcers having a punched-out 
appearance; ulceration of uvula, velum, and tonsils; very offensive 
odor ; ptyalism ; loose teeth. Used as a gargle in water and 
given internally in the 3 x. 

Psorin. — Especially in the congenital form, with ozsena, 
offensive otorrhoea, etc. 

Sulphurous ac. — For ulceration ; locally, as a spray of a 
5-per-cent solution of the dilute acid, and internally in the 6 x. 
(Compare " Syphilis of the Nose " and " Syphilis of the Larynx.") 

CONGENITAL HEREDITARY SYPHILIS. 

This affection nearly always manifests itself before the age 
of puberty, and, in about half the cases, within the first year 
of life. It is believed that the secondary stage very generally 
appears during uterine life. The pharyngeal ulcerations are 
often quite deep and may attack any part, although the soft 
palate is a frequent site, between which and the pharynx ad- 
hesions very often occur. There is a special tendency for the 
ulceration of congenital syphilis to attack the median line and 
to involve the bone. The appearance of the ulcers is not unlike 



SCROFULOUS PHARYNGITIS. 251 

that of the tertiary stage of acquired syphilis. Congenital 
syphilis rarely attacks the oesophagus, but the nose is often ulcer- 
ated. The larynx suffers less frequently than in the acquired 
affection. 

Infants affected with hereditary syphilis usually have some 
nasal disorder, chiefly the so-called " sniffles " ; excoriation and 
ulceration of the alee or lip ; perhaps pegged teeth ; the peculiar 
triangular frontal prominence ; the withered, pinched appear- 
ance, etc. 

Prognosis. — The prognosis is usually good after the first 
year of life, but ulceration occurring prior to that age may prove 
fatal, and the probability of various contortions, stenoses, and 
disfigurements must be borne in mind. The voice may be per- 
manently destroyed. 

For treatment, see the preceding subject, as well as 
" Syphilis of the Nose." 

SCROFULOUS PHARYNGITIS. 

Although some authors deny the existence of a scrofulous 
pharyngitis, there is sufficient proof of such an affection to 
justify its consideration. It seems rarely to be ulcerative in 
nature, unless complicated by phthisis, syphilis, or lupus. It 
might be added that it is sometimes extremely difficult to dis- 
tinguish phthisical, syphilitic, or lupoid ulcerations when com- 
plicated by a strumous diathesis ; and yet there are some well- 
outlined characteristics, upon which the diagnosis of a strumous 
complication can be based. 

The cause is constitutional. 

Pathology. — Pathologically, it is characterized by a low 
grade of inflammation of the pharyngeal or cervical glands ; the 
former often undergoing ulceration, — at first, superficial and 
indolent ; later, deep and perforating. Often the follicles of the 
pharynx, the tonsils (pharyngeal and faucial), and pharyngeal 
mucous membrane participate in the thickening. The cervical 
glands may undergo ulceration or cheesy degeneration. 



"252 DISEASES OF THE NOSE AND THROAT. 

Scrofulous ulceration of the pharynx has peculiarities 
which, though they serve to differentiate the condition from the 
preceding forms of ulceration, usually go hand-in-hand with 
one of them. It is not impossible, however, to have distinct 
strumous ulcers, which are so very like those found in well- 
determined congenital syphilis that the old question will arise : 
"Are the two conditions one and the same, or are they dis- 
tinct 1 " The ulceration is usually slow, and, although ap- 
parently cured, often persistently returns, until the soft tissues, 
or even the hard palate, may be nearly destroyed. The ulcer 
starts as a small point of thickening, frequently near the base 
of the uvula, and spreads slowly. While there is no well- 
marked areola, as in syphilis, the mucous membrane surround- 
ing the ulcerating portions is often much indurated and the 
pharyngeal follicles are very prominent. The surface of the 
pharynx is covered with a dirty, mottled coating, and tenacious 
mucus often completely covers the ulcer. As there is but little 
granulation tissue, there is little or no tendency to heal ; con- 
tractile tissue is rarely developed, but adhesions occasionally 
occur between the soft palate and the pharyngeal wall, effect- 
ually obstructing the naso-pharyngeal opening. In its ravages 
the ulceration may not only destroy the soft tissue, but bone 
and cartilage as well ; thus, the hard palate, nasal septum, and 
turbinated bones are sometimes sacrificed. 

Symptoms. — The chief symptoms of scrofulous pharyngitis 
are a sense of thickness in the pharynx, tenacious discharge, 
and painful and enlarged (chiefly anterior) cervical glands. 
The voice is often affected from implication of the nose and 
larynx. If ulceration be present, these symptoms are aggra- 
vated. When the nose and palate are ulcerated, food will 
regurgitate through the posterior nares and the senses of smell 
and taste will be impaired. Should the larynx suffer, vocal 
defects will follow ; and when the Eustachian tubes are affected, 
pain is usual and the hearing generally impaired. 

Prognosis. — The prognosis is usually good, although at 



LUPUS OF THE PHARYNX. 253 

times there is much destruction of tissue, greatly impairing 
vocalization, deglutition, respiration, smell, taste, and hearing. 

Treatment. — One of the first rules in the treatment of 
scrofulous ulceration is cleanliness ; beyond this, the case must 
be treated upon purely constitutional grounds. In addition to 
the internal remedy, great benefit is often derived from atten- 
tion to hygiene and diet and from the use of codliver-oil and 
terraline. It is unwise, as a rule, to apply caustics with the 
hope of limiting the ulcerative process, but the galvano-cautery 
is occasionally successful. Should bands of cicatricial tissue 
obstruct nasal respiration, they are to be dealt Avith as suggested 
under " Stenosis of the Pharynx." 

Therapeutics. 

Bromine. — Scrofulous ulceration, with threatened gangrene. 

Ignat. — In conjunction with enlarged tonsils and right 
external cervicals, especially in very nervous persons. 

Iodine. — Glands large, much hardened, and torpid. The 
ulcers have spongy edges ; discharge bloody and ichorous or 
purulent. In spite of a good appetite, the patient grows thin. 
I look upon this last symptom as almost unfailing. 

Compare calc. c, fer. iod., psor., silica. (See " Scrofula of 
the Nose.") 

LUPUS OF THE PHARYNX. 

There seems to be a certain but undefined association be- 
tween this affection and scrofula, for lupus is most frequent in 
scrofulous subjects, especially in young females. The relation- 
ship between lupus and phthisis is undoubted. Lupus of the 
pharynx may be either primary or secondary ; the latter is 
usually found in connection with lupus of the skin about the 
face, but it not infrequently complicates lupus of the nose or 
larynx. 

Symptom*. — According to Schech, its favorite localities are 
the tonsils and soft palate ; the former appear rough, enlarged, 
and covered with excrescences, with ulceration of the intervening 



254 DISEASES OF THE NOSE AND THROAT. 

tissue. When the soft palate is affected, Krause notes the 
presence of confluent, hard, dark-red nodes on a normal or pale 
mucous membrane ; superficial or perforating ulcers, with hard, 
everted edges and excavated base, may supplant these nodes ; 
or the latter may shrivel, leaving the surface nearly normal. 
The disease is usually unattended by pain. Tubercle bacilli are 
sparingly found. 

Its appearance is not unlike that of syphilis, from which 
it may be distinguished by the history, the slow progress, the 
nodular appearance, the much less marked areola, the frequent 
presence of cutaneous lupus, and the absence of other manifes- 
tations of syphilis. 

It diners from phthisis, in that the lupoid mucosa is not so 
pale ; where ulceration occurs, the depth of the lupoid ulcer is 
greater and it is surrounded by a slight areola. 

The uvula is often solidly infiltrated, club-shaped, and 
generally congested and nodulated. 

Prognosis. — The prognosis is favorable. When the ulcers 
heal, the resulting scars are sensitive and often occasion marked 
cicatricial contractions. The disease is chronic, often lasting- 
many years. 

Treatment. — Since scrofula is its most frequent ally, the 
antiscrofulide remedies should be used in conjunction with fresh 
air, exercise, good nourishing diet, regular hours for sleeping 
and eating, cold sponge-baths, vigorous rubbings, and the in- 
ternal use of codliver-oil, malt, or terraline. When syphilis 
complicates the affection, similar treatment may be needed, with 
the addition of kali iod., mere, etc. Locally, thuja occid. may 
be used in the tincture ; but if ulceration steadily progress in 
spite of these remedies, the diseased tissue should be thoroughly 
removed with the curette or galvano-cautery. If the uvula 
alone be involved, it should be amputated. Following these 
operations the parts are to be thoroughly coated with a 50-per- 
cent solution of lactic acid. 



LEPROSY OF PHARYNX. 255 

LEPROSY OF THE PHARYNX. 

The pharynx is rarely invaded by leprosy, which, according 
to de la Sota, occurs in this organ only in the tubercular form, 
and is always secondary to the skin affection. The pharyngeal 
eruption starts as a bright-red spot, which soon becomes tuber- 
culous ; it is quite insensitive, white, and soft. The nodes 
which form are smaller than those of lupus, and the ulcers, like 
the eruption, are soft and insensitive. 

The affection is exceedingly rare, but, when it occurs, a 
hopeless prognosis must be given. 

The treatment is little more than palliative ; hygienic and 
dietetic measures should be employed, but all operations are to 
be avoided as likely to augment the destructive process. 

(See " Leprosy of the Larynx.") 



CHAPTER XX. 

Tumors and Foreign Bodies. 



TUMORS OF THE PHARYNX. 

Pharyngeal tumors are rare, and, as a rule, are not recog- 
nized very early, as their presence, if benign, seldom creates 
marked symptoms. Fibromata, osteomata, enchondromata, papil- 
lomata, and cysts are the benign forms : the malignant tumors 
are encephaloid, epitheliomata, and lympho- and fibro- sarcomata. 
Benign pharyngeal growths are always primary, but malignant 
neoplasms may start in some neighboring part and extend to 
the pharynx, or they may appear in the pharynx as a secondary 
manifestation. Both benign and malignant growths are usually 
situated in the tonsillar region, on the soft palate, or in the 
lateral pharyngeal walls ; but it is not impossible for them to 
occur in the posterior wall, where they give rise to symptoms 
closely corresponding to retro-pharyngeal abscesses. Syphilitic 
outgrowths sometimes occur. One of the rarest tumors of the 
pharynx is that which occurs from an overgrowth of the occa- 
sional physiological extension of the thyroid gland to the pos- 
terior part of the pharynx, nearly on a level with the lower part 
of the epiglottis. Sarcomata and fibro-sarcomata sometimes 
invade this thyroid structure. It is well to remember the 
occasional presence of aneurism of the internal carotid artery 
and the danger of mistaking*it for a new growth. Carcinoma 
is the most frequent form of ulcerative tumor of the pharynx ; 
sarcoma is very infrequent. Either form may extend to the 
larynx. 

The pathology need not be given. 

Symptoms. — The symptoms are often unimportant. In 
benign tumors the first annoyance, generally, is a sense of full- 
ness in the throat, cough, or dysphagia; difficult respiration 
(256) 



TUMORS OF THE PHARYNX. 257 

usually appears late. In malignant growths pain is often the 
first symptom, but at this time it is rarely severe ; later, how- 
ever, during the ulcerative period, it is usually intense, especially 
during deglutition, although it may not appear at any time. 

Early in the history of most pharyngeal growths the swell- 
ing is hard, smooth, roundish in outline, and is sometimes indis- 
tinguishable from ordinary hypertrophy of the tissues. When 
the tonsils are involved, it is often impossible to differentiate the 
condition from an ordinary chronic hypertrophy of these organs, 
but the subsequent ulceration and pain of cancer facilitate the 
diagnosis ; and epithelioma is often strawberry-like preceding 
ulceration. (See Fig. 66, page 259.) 

It is important to distinguish neoplasms from abscesses and 
aneurisms : the usual tests are to be applied here as elsewhere ; 
however, it is almost impossible to auscultate for aneurism, but 
a decided aneurism al throbbing and thrill may be detected in the 
region of the growth. Cysts and abscesses are so similar that 
the history or the exploring needle alone draws the line of 
demarcation. The diagnosis of thyroid gland-tissue is difficult, 
unless the tumor rise and fall freely during deglutition. 

Prognosis. — The prognosis of malignant tumors of the 
pharynx is grave. Medicines appear to cure some and early 
extirpation a few, but the majority prove fatal in from a few 
months to two or three years. Benign neoplasms are not gen- 
erally fatal, as nearly all can be either reduced in size or re- 
moved. Pressure of the tumor upon the superior laryngeal 
nerve may induce vocal defects or anaesthesia of the mucous 
membrane. 

Treatment. — If large, there is constant danger of suffocation 
or inanition : for the relief of the former, extirpation, tracheot- 
omy, or laryngotomy will be required ; and, for the latter, 
removal, the stomach-tube, nutritive enemata, inunctions, or 
gastrotomy. Extirpation may be accomplished with the knife, 
scissors, forceps, snare, or galvano-cautery. Electrolysis is the 
best method of gradual reduction : should the latter fail it may 



258 DISEASES OF THE NOSE AND THROAT. 

become necessary to remove the growth by subhyoid pharyn- 
gotomy. Malignant tumors may occasionally call for resection 
of the pharynx. 

In the early stage of pharyngeal tumors, internal remedies 
are of prime importance. Later, should the ulceration and 
odor be pronounced, soothing, cleansing, and disinfectant sprays 
and washes are indicated as adjuncts. 

For therapeutics, see " Tumors of the Nose " and " Tumors 
of the Larynx." 

CANCER OF THE TONSILS AND PALATE. 

Symptoms. — This affection is rare and nearly always 
primary. Lympho-sarcoma, soft scirrhus, and epithelioma are 
the usual forms. The tonsil is greatly inflamed and swelled, 
but usually soft ; haemorrhage is frequently severe, even fatal ; 
pain is often excruciating and may render deglutition practically 
impossible. The voice is always nasal, and nasal and oral 
respiration may be impaired. When the soft palate is alone 
involved, the ulceration may destroy the pillars of one or both 
sides, and, later, invade the tonsil and lateral or posterior phar- 
yngeal wall. At times the uvula and pillars may be ulcerated 
on one side only; later, the opposite arches may break clown, 
beginning near the tonsil and creeping up, thus giving rise to 
two independent ulcerating areas. The discharge is thin, 
sanious, and often copious. If there be no actual hypertrophy 
of the glands at the angle of the jaw, there is usually tenderness 
in that region. The tonsil itself does not always seem much 
enlarged, as infiltration of the surrounding structures may con- 
ceal it. The mass usually imparts to the finger, as expressed 
by McBride ("Diseases of the Throat, Nose, and Ear"), "the 
characteristic fixed, indurated feeling of malignant disease." 
Loss of bodily flesh and strength is rapid and progressive. 

Sarcomata are usually dusky red, with extensive areolae ; 
epitheliomata usually appear as paler, warty excrescences, or 
cauliflower growths. 



CANCER OF THE TONSILS AND PALATE. 



259 



Diagnosis. — Cancer of the tonsil, though it simulate 
syphilitic ulceration of this organ, is usually easy to diagnose. 
The pain of the former is often constant, usually lancinating, 
and may prevent deglutition ; but the pain of syphilis is generally 
slight, rather a soreness, except during deglutition, which is 
sometimes very difficult and painful, but rarely impossible. The 




Fig. 66.— Primary Epithelioma of the Right Tonsil. 
(From a photograph kindly taken by Dr. N. W. Fryer.) 

glandular involvement of cancer is quite extensive and tender- 
ness is marked ; whereas syphilis has usually less glandular 
enlargement, except post-cervically, and the glands are less 
tender. The ulcer of cancer has a very broad areola ; that of 
syphilis rarely more than one- third of an inch ; and the former 
affection has frequent, often profuse, haemorrhages ; the latter 



260 DISEASES OF THE NOSE AND THROAT. 

rarely bleeds. The general emaciation of cancer is out of pro- 
portion to the decline in appetite ; that of syphilis follows this 
decline. 

Prognosis. — The prognosis is grave in tonsillar cancer, 
unless the gland be excised early. Haemorrhage often gives 
temporary relief. Death may occur in two or three months, 
or only after as many years ; it is often sudden when due to 
haemorrhage or to oedema of the larynx. The prognosis of 
faucial cancer is less grave ; recovery may follow, and death is 
rarely caused by haemorrhage, unless the tonsils be secondarily 
ulcerated. 

Treatment. — The treatment varies from that already noted 
under " Cancer of the Pharynx " only in case it be advisable 
and possible to extirpate the tonsil. I do not advocate the use 
of the galvano-cautery, as it sometimes appears to hasten the 
destructive process. Acids are alike to be condemned. Ex- 
cision of portions of the growth projecting into the faucial 
space often gives decided relief for a few weeks, and does 
not appear to act detrimentally. It is, at times, possible to 
thoroughly extirpate the tonsil and diseased peritonsillar 
tissue by an incision along the anterior border of the sterno- 
hyoid muscle. Calendula (20 per cent) may be used both 
internally and locally, with some degree of confidence that it 
will lessen the pain and discharge, and possibly the ulcerative 
activity. (See case by Dr. C. Weaver, Trans. Homoeo. Med. 
Soc. of Pa., 1890.) 

For therapeutics, see " Cancer of the Nose " and " Cancer of 
the Larynx." 

FOREIGN BODIES IN THE PHARYNX. 

Any substance not too large may lodge in the pharynx, 
but sharp-pointed or angular objects are apt to occasion most 
annoyance. Pins, needles, fish-bones, and splinters frequently 
pierce the tonsil or lie transversely in the pharynx, where mus- 
cular contraction forces them into the tissues. Smooth, roundish 
substances generally fall into the pyriform sinuses or valleculas, 



FOREIGN BODIES IN THE PHARYNX. 261 

and if early search be made in these spaces much time will often 
be saved and great annoyance obviated. 

If the foreign body be small, little inconvenience may be 
occasioned, although a very minute substance may cause great 
annoyance in the way of sticking, shooting pain, aggravated by 
swallowing. Pieces of oyster or other shells, wheat-hulls, etc., 
give rise to similar symptoms, in addition to which there is 
often the sensation of a scale adherent to the throat. Large 
bodies occasion fullness and difficult deglutition, and, when im- 
pacted above the epiglottis, this cartilage may be forced down 
upon the laryngeal vestibule, producing difficult or impossible 
respiration. 

It is not unusual either for the foreign body to be expec- 
torated or to pass on to the stomach. It is not always easy, 
however, to convince the frightened patient that such a result 
has followed ; for the presence of the offender may have occa- 
sioned considerable irritation, or even inflammation, thus giving 
the impression that the object is still in the throat. It must be 
remembered that there are many hysterical cases in which the 
patient is "convinced" of the existence of some extraneous 
substance when none has been present (paresthesia). 

In searching for foreign bodies a head-mirror should be 
used for the purpose of illumination. In the absence of dysp- 
noea, leading to the position of the body, the tonsils and fauces 
should first be examined. The object may be nearly buried 
and very difficult to see, as only a small portion may project. 
When found, it can generally be readily removed with ordinary 
long dressing forceps. Failing to find it, search should be 
made deeper in the pharynx, especially in the valleculas and in 
the pyriform sinuses ; next, in the base of the tongue, among 
the rouges ; and, finally, in the laryngo-pharynx. 

It is often easy to remove small bodies from the valleculas 
by catching them under the nail of the index finger ; but if 
they lie below this level, forceps will be required for their 
extraction. When they press upon the epiglottis, the finger 



262 DISEASES OF THE NOSE AND THROAT. 

can usually be made to answer the purpose of a hook, but it 
must pass well below the object, otherwise fatal dyspnoea may 
be occasioned by impacting the epiglottis or the foreign body 
into the larynx, usually necessitating a hasty tracheotomy or 
some other means noted under " Foreign Bodies in the Larynx." 
If the body be behind the larynx and cannot be extracted, it is 
advisable to push it into the oesophagus. When in the upper 
pharynx, care must be exercised not to force the intruder into 
the deeper air-passage. 

It will sometimes require considerable care, patience, or 
ingenuity, to extract a large or an irregular substance. In the 
absence of either forceps or a sufficiently-long finger, a piece 
of smooth wire may be bent into the form of a hook and gently 
insinuated beyond the mass ; both may then be carefully with- 
drawn. A very simple device, which is occasionally successful, 
is to excite reflex pharyngeal action by blowing into the ear. 

The laryngoscope should be used for examination of the 
space below the tonsils and back of the half-arches, but in its 
absence the index finger may be introduced into the throat, 
using the right finger for examination ot the right side of the 
throat and the left for the opposite side, so that the palmar sur- 
face is always directed toward the sides of the passage. In this 
way inequalities are more readily detected. If the object can- 
not be found at the first examination, and if the patient still 
feel the sticking, a second or a third search should be instituted. 

When not practicable or possible to extract the body, there 
is clanger of its dislodgment and entrance into the deeper air- 
passages ; but when dislodged, it is usually expectorated. When 
removed, a few doses of aeon, or fer. phos. should be given 
to allay the irritation. Under foreign bodies in the pharynx 
should be noted an unusual accident : that of partially swallow- 
ing the tongue. It has occurred in children during whooping- 
cough, and in hysterical adults. It gives rise to pharyngeal 
dyspnoea, relief from which comes when the tongue is thrust 
or pulled forward. In one case reported by Ingals. a hysterical 



FOREIGN BODIES IN THE PHARYNX. 263 

woman had such a condition characterized by spasmodic con- 
traction " of the hyo-glossus and probably also the stylo-glossus 
muscles, which drew the tongue into the pharynx in such a 
position as to prevent respiration." ("Diseases of the Chest, 
Throat, and Nasal Cavities.") • 



CHAPTER XXI. 

Stenosis, Dilatation, Malformation. 



STRICTURE OF THE PHARYNX STENOSIS. 

Etiology. — This affection is a sequel of some of the ulcer- 
ative diseases. Syphilis (acquired or congenital) stands pre- 
eminent ; next follow scrofula, lupus, diphtheria, and acute 
ulcerations due to the exanthemata. 

It may manifest itself in the form of stenosis of the upper 
or lower pharynx or both. The most frequent form is that in 
which one posterior pillar of the fauces is adherent to the pos- 
terior wall of the pharynx ; this may be slight or so extensive 
as to draw the soft palate well back toward the pharynx. Next 
in order is the attachment of the soft palate to the pharynx ; 
this usually closes the greater part of the space between the 
naso- and oro- pharynx, but a complete closure of this orifice is 
the rarest of all forms of pharyngeal stenosis. As a rule, the 
uvula is destroyed ; but where intact it usually stands out in 
the median line, in front of the remaining naso-pharyngeal pass- 
age. The pharynx may be divided, into two lateral portions, 
by a. band of tissue passing from the back of the soft palate and 
uvula to the pharynx. The Eustachian tubes may be closed. 

When the lower pharynx suffers there is usually a band of 
cicatricial tissue running from the posterior wall of the pharynx 
to the base of the tongue, generally just above the tip of the 
epiglottis. In such patients the larynx is sometimes hidden 
from view. 

Symptoms. — The symptoms vary from slight difficulty of 
deglutition, regurgitation of food, and nasal intonation to oblit- 
erated nasal respiration, loss of voice, taste, and smell, and in- 
ability to breathe or swallow. Thus, efforts at deglutition 
mav be restricted to small quantities of fluid food, which are 
(264) 



STRICTURE OF THE PHARYNX STENOSIS. 265 

forced down with evident effort ; solid food may lodge in the 
opening and give rise to fatal dyspnoea, unless promptly dis- 
lodged. When the action of the epiglottis is hindered, food 
may pass into the larynx, but, as a rule, the sphincter of the 
larynx prevents this. 

Prognosis. — The prognosis is not always unfavorable : the 
voice may not be completely restored, deglutition may remain 
imperfect, and death may result from dyspnoea. 

Treatment. — It is usually inadvisable to interfere mechani- 
cally unless the functions be markedly impaired, since it is 
frequently difficult to prevent the re-attachment of the diseased 
structures. If the soft palate be adherent to the pharynx it can 
often be dissected off; after which it is necessary repeatedly to 
cover one side of the incision with flexible collodion until granu- 
lation is complete. This, however, often fails, and the stricture 
becomes as tight as before. The soft palate may be forcibly 
drawn forward by a silver plate passed through the new open- 
ing and held in position by two springs passing to the upper 
teeth, as recommended by Kuhn ; or one end of an elastic band 
may be passed through one nostril, the second end through the 
other, the loop coming in contact with the columella in front 
and the free ends tied by a thread to the upper incisor teeth. 
Plates and tubes have also been devised, but are not satisfactory. 
Sometimes the passage from the oro- to the naso- pharynx is 
completely obliterated by cicatricial changes ; in such a case it 
was formerly advised to cut a small opening through this struc- 
ture for the easy passage of air ; the hole was not to be large, 
owing to the danger of the regurgitation of food. This opening- 
was then to be enlarged, if possible, by the daily passage of 
probes, and, later, either of bougies of gradually increasing 
sizes, dilating tents, elastic bags, or forcible dilators. This can 
sometimes be accomplished by frequently introducing the finger 
and drawing the soft parts forward. 

The galvano-cautcry occasionally succeeds in making a 
permanent opening, but, as all of the preceding measures are 



266 DISEASES OF THE NOSE AND THROAT. 

uncertain, Jas. E. Nichol presented to the New York Academy 
of Medicine, January 28, 1890, the most rational, scientific 
method of accomplishing this result. With all methods the 
tendency is for adhesions to re-form, starting at the incision 
extremities, and gradually but persistently creeping to the centre. 
Dr. Nichol's method is as follows: When a central opening 
does not exist, he makes one by the following method : A metal 
bougie or catheter is passed through the inferior nasal meatus 
and made to push the stenotic tissue well down in the median 
line; upon this, as a guide, he thrusts a narrow knife-blade 
from the oro-pharynx. A staphylorrhaphy needle, curved to 
the right or left, as desired, is next threaded with several strands 
of coarse silk. The point is introduced through the central 
opening and brought back into the oro-pharynx, as near the 
lateral wall as possible. As the tissues are very elastic, counter- 
pressure should be exerted by a heavy probe ; care must be 
exercised not to include the palato-pharyngeus muscle. The 
silk is now to be pulled from the eye of the needle into the oro- 
pharynx and the needle removed. The ends of the silk are to 
be loosely tied so that a loop is formed with the seton passing 
through both openings. If deemed advisable, the other side is 
treated in the same manner. A general anaesthetic will rarely 
be required, but cocaine should be applied before the operation. 
The loop should be moved daily until healing is effected (ten to 
fifteen days), when the loop is drawn forcibly toward the median 
line, and a blunt-pointed bistoury introduced into the lateral 
opening; great care is necessary not to nick the newly-healed 
tissue except on its median line ; the tissues are then divided 
from the lateral to the central opening. The raw surfaces are 
to be kept apart by some of the measures previously suggested. 
If the Eustachian tubes be stenosed they can usually be 
dilated by the careful passage of catgut bougies introduced 
through a Eustachian catheter (Fig. 35, page 103) ; if entirely 
closed, an effort should be made to open a passage with the 
knife, guided by the mirror ; this must be followed by repeated 



DILATATION OF THE PHARYNX PHARYNGOCELE. 267 

use of the bougies. If this fail, and hearing be impaired, it is 
often advisable to exsect a piece of the membrani tympani and 
perhaps the hammer-handle, with the hope of improving the 
hearing and tinnitus aurium. 

When the lower portion of the pharynx is the part 
affected, attention must be first directed to the opening to see 
that it is large enough to admit a good supply of air. When 
advisable, the passage can be enlarged either by Schlatter's hard- 
rubber bougies (see " Stenosis of the Larynx ") or, more satis- 
factorily, a form of intubation-tube. It can, however, be 
speedily enlarged with the bistoury or galvano-cautery, after 
which the opening should be frequently and forcibly dilated. 

DILATATION OF THE PHARYNX PHARYNGOCELE. 

Enlargement of part of the pharynx is not a rare change. 
It is chiefly confined to the laryngo-pharynx, often in conjunc- 
tion with dilatation of the oesophagus. The oro-pharynx is 
sometimes pouched, but the naso-pharynx is never dilated. As 
a rule, the pouch forms at the back part of the pharynx and 
finds its way between the posterior wall of the oesophagus and 
the spinal column. This diverticulum is formed of the mucous 
and submucous tissues which have been pushed between the 
muscular fasciculi ; on this account the late Sir Morell Mac- 
kenzie very aptly termed it a hernia. 

Etiology. — Pharyngocele is occasionally congenital ; if 
acquired, it probably arises from weakness of the muscular and 
submucous coats, either inherent or from disease or injury. 
Temporary lodgment of food in the pharynx and the habit of 
" bolting " the food, seem to act as excitants to pharyngeal dila- 
tation. Hernias may occur above a constricted portion of the 
pharynx (tumor, aneurism, or cicatricial tissue), if the food be 
forced downward upon the obstacle by strong action of the 
constrictor muscles. 

Symptoms. — The chief symptoms are difficult or impossible 
deglutition of solid food and the ejection, from time to time, of 



2G8 DISEASES OF THE NOSE AND THROAT. 

particles of food ingested, portions of which may enter the larynx 
or deeper parts, giving rise to spasm or dyspnoea, on the one 
hand, or bronchitis or pneumonia, on the other. As a rule, the 
patient subsists on liquid food. 

Diagnosis. — The diagnosis is not usually a difficult matter. 
The affection bears a resemblance to stricture of the oesophagus, 
but is unlike it, in that it is devoid of either nausea or retching, 
and that food is returned piecemeal, instead of in quantity. 
When there is a sac the patient feels a fullness after meals, and 
a reducible tumor is often detected externally ; when emptied, 
immediate ejection of food follows. Such a tumor does not 
exist in oesophageal stricture, unless accompanied by dilatation, 
when the location makes the diagnosis clear. If a laryngo- 
scopy; mirror be used, the diverticulum can readily be seen, if 
large or generally dilated ; a probe will greatly assist the diag- 
nosis, although the opening may be too small to be detected 
either with the eye or probe. 

Prognosis. — The prognosis is rarely favorable to a cure, 
although a fatal issue is infrequent, even from suffocation, 
pneumonia, or abscess formation. 

Treatment. — The treatment is chiefly mechanical, but 
Nature sometimes cures by the establishment of inflammatory 
adhesions. Where the muscles are weak, the galvanic current 
may aid the internal remedies, or a brace and collar may be 
adjusted; but where there is an actual pouch, cutting instru- 
ments are needed to cure. If there be no suffocative attacks, 
and if by pressure the patient can prevent the entrance of 
food into the pouch, it is better not to operate; but should 
suffocation occur, the pharynx must be opened and the sac 
excised. In order to prevent rupture of the wound-edges 
during the healing process feeding-tubes are necessary, and 
in order to guard against later stricture bougies should be 
used. 

The remedies best indicated are gels., ignatia, mix vom., 
and strych. 



CONGENITAL MALFORMATIONS OF PHARYNX. 



269 



CONGENITAL MALFORMATIONS OF THE PHARYNX. 

The most frequent malformation of the pharynx is promi- 
nence of one or more of the cervical vertebrae ; as a rule, one 
side projects more than the other. For such a condition noth- 
ing can be done, and generally nothing is required, since it 
gives rise to no inconvenience. Lennox Browne gives the his- 
tory of a rather unusual alteration somewhat analogous to the 
preceding, namely, "angular curvature of the cervical portion 
of the spinal column." In this case the condition, although it 
had always existed, had caused 
no annoyance in early life ; but 
after an attack of "Indian fever" 
he had noticed difficulty in respi- 
ration and deglutition, which was 
instantly relieved by elevating the 
chin and occiput, thus straighten- 
ing the cervical vertebrae. A sup- 
port was adjusted with happy 
effect. 

The next most frequent mal- 
formation is, perhaps, a division 
of the uvula. It may be split 
from tip to base, but, as a rule, 
only the lower part is bifid ; the 
two portions generally remain in contact, but with true bifid 
uvula the lower extremities stand out as two diverging horns. 
For this condition nothing is usually required ; it may, however, 
cause vocal defects in singers, when the opposing edges should be 
freshened and united by stitches. The condition is sometimes 
so extensive as to form a cleft palate. The uvula is at times 
very large ; at others, small or even wanting ; or, again, turned 
to one side, etc. Instances are not wanting in which there is a 
uvula on each side of the faucial space. 

The tonsils are at times either congenitally large, small, 
absent, or doubled. 




Fig. 67.— Separate* Mucous In- 
vestment of the Palato-Glossus 
Muscles. 



270 DISEASES OF THE NOSE AND THROAT. 

The naso-pharynx is sometimes divided vertically by a 
ridge of bone, the backward continuation of the nasal septum. 
This may give rise to few if any symptoms, but may often inter- 
fere with deglutition and impair vocal tones. Such a septum can 
be broken down with forceps or cut out with a saw or electric 
drill. The naso-pharynx may be separated from one or both 
nasal canals by a bony or fibrous plate, destroying the sense of 
smell, the natural voice, and nasal respiration. If bony, such a 
partition should be drilled or broken down with chisel and 
forceps ; or, if fibrous, cut with a knife or galvano-cautery blade. 

The anterior half-arches are rarely congenitally perforated, 
but Cohen has pictured one such case in his "Diseases of the 
Throat and Nasal Passages." Four others have been reported, 
and Fig. 67, on preceding page, represents such a condition in 
one of my patients. The anomaly is due to a separate mucous 
investment of the palato-glossus muscles. 

Finally, the styloid process is occasionally elongated and 
passes as far down as the posterior portion of the tonsil, or pro- 
jects toward the middle line of the pharynx, interfering with 
deglutition. It can be broken off by forceps. 



CHAPTER XXII. 

Neuroses of the Pharynx, 



SENSORY CHANGES. 

Anaesthesia arises from a central change (cerebral anaemia, 
haemorrhage, or tumor), injury to the nerve-trunks or twigs, 
local lesion, general depressing disease, hysteria, or insanity. 
Diphtheria is the most frequent cause of the loss of sensation in 
the pharynx. Anaesthesia following the use of various drugs — 
chloroform, morphine, cocaine — should not be classed under this 
heading. 

Symptoms. — The symptoms are : loss of sensation, deter- 
mined by the probe or electricity and aided by the patient's 
statements. Deglutition is frequently difficult, and food often 
passes into the larynx, owing to loss of sensation in both pharynx 
and larynx. 

Prognosis. — The prognosis is usually good, but, if neglected, 
anaesthesia of the pharynx may prove fatal either as the result 
of inanition or of pneumonia, due to the entrance of food into 
the lower air-tract. 

Treatment. — The treatment is chiefly medicinal, but galvan- 
ism and faradism play an important role in its cure. If the 
food frequently pass into the larynx, the patient should be fed 
with the oesophageal tube ; neglect of this precaution has led to 
fatal results, although it is sometimes difficult to convince the 
patient that the procedure is an absolute necessity. 

■ The remedies best suited to the case are bo vista, caust., 
gels., iodoform, rhus tox., and strych. 

Hyperesthesia is of frequent occurrence ; in some persons 
the pharynx is so irritable that it is almost impossible to intro- 
duce a laryngeal mirror to the posterior part of the pharyngeal 

(271) 



272 DISEASES OF THE NOSE AND THROAT. 

cavity ; and it is not unusual to meet with cases in which no 
instrument can be passed beyond the teeth. In the latter con- 
dition the hyperaesthesia is chiefly mental, although it may be 
exaggerated by a local catarrhal or other cause, which superin- 
duces irritability of the terminal nerve-fibres. The usual cause 
of hyperaesthesia is catarrhal congestion, although it may arise 
from an elongated uvula, enlarged tonsils, tumors, gouty dia- 
thesis, use of alcoholic drinks, tobacco, and condiments. 

Symptoms. — The symptoms usually manifest themselves as 
reflex irritability from contact of a probe, etc. ; there is little or 
no pain, unless a hard or dry substance come in contact with 
the pharynx. The results are generally favorable. 

Treatment. — The treatment is chiefly internal, though 
various forms of gargles and sprays have been recommended, 
chiefly those useful in allaying irritability elsewhere ; morphine, 
chlorate of potassium, chloroform, and ether have their advocates. 
If it be advisable to use a local remedy, cocaine spray is the 
best for temporary purposes, as in making examinations ; but 
for curato-palliative purposes, bonbons of malt and sugar act 
favorably. 

The remedies most frequently applicable are hyos., ignatia, 
and mix vom. 

Paresthesia (abnormal sensations) is an affection of rather 
usual occurrence. It is most frequent in those who are ner- 
vous, neurasthenic, or actually hysterical ; and is infrequent in 
catarrhal subjects, follicular and vascular pharyngitis excluded. 
Varicose veins at the base of the tongue are undoubted excitants. 
Paraesthesia sometimes arises reflexly from excessive use of the 
voice, and from alcoholism. Finally, it may be due to cerebral 
change, occasionally bulbar paralysis. 

Symptoms. — The most frequent manifestation of paraesthe- 
sia is in the familiar globus hystericus ; it not infrequently 
asserts itself, however, as a foreign body, — ball, stick, bone, 
hair, etc. In this aberration the eye can detect no change. 



SENSORY CHANGES. 273 

This form of neurosis is often most intractable, but occasionally 
one well-directed prescription will cure ; recovery is generally 
the rule. 

Treatment. — The management of paresthesia is chiefly me- 
dicinal, although local measures may be of utility, and physical 
control is often of inestimable value. Varicose veins may 
require the use of the galvano-cautery point or acid nitrate of 
mercury. One of the best local applications is a 20-per-cent 
glycerin solution of chloride of zinc. Internally, cuprum, ham., 
hyos., ignatia, and rhus tox. are of frequent use. 

Neuralgia of the pharynx shows itself in the form of severe, 
sharp, darting pains. If the probe be passed over the tonsils 
and pharyngeal mucous membrane, it is often possible to detect 
a spot of exquisite sensitiveness ; this may be occasionally found 
by external manipulation. No pathological changes are dis- 
cernible. Few cases occur in other than very nervous persons, 
and those who suffer from amenorrhcea or dysmenorrhea. It 
may be said of most of the neuroses of sensation, that they are 
often reflex manifestations of uterine disorders and chlorosis. 

Treatment. — Treatment should be directed to the general 
disorder, of which the neuralgia is usually a part or a sequel. 
It is both electrical and medicinal. Agar., bell., ignatia, and 
mag. phos. are the chief internal remedies. 

Reflex phenomena sometimes occur, especially from enlarged 
tonsils ; they consist of pain in the ear, spasmodic cough, vom- 
iting, and chorea. 

Pharyngeal blushing consists in a temporary reddening of 
the mucous membrane, the result of vasomotor disturbances. 
It is often associated with hyperesthesia of the pharynx and 
oesophagus, but there is a question as to the association being 
in the relationship of cause and effect. 

No treatment is required. 



274 DISEASES OF THE NOSE AND THROAT. 

MOTOR CHANGES. 

Spasm of the pharyngeal muscles is quite a rare condition. 
Although the constrictors are chiefly affected, the palatine, the 
upper oesophageal, and even the palato-tubal muscles may share 
and complicate the case. The muscles are sometimes affected 
simultaneously ; sometimes individually. In one recorded case 
the larynx and floor of the mouth were elevated. 

Spasms of the pharynx may occur in the hysterical, in those 
affected with acute catarrhal and cedematous conditions, or in 
those in whom there is some brain-lesion. Hydrophobia and 
tetanus (trismus) are always complicated by these spasms. 

The diagnosis is easy, and is assured by the sudden and 
complete tonic contraction of the muscles implicated. 

The prognosis is usually good, unless the spasm be a com- 
plication of such maladies as trismus and lissa. 

The chief remedies are agar., cuprum, gels., and mag. phos. 

Paralysis is the most important of the pharyngeal neuroses. 
It may be central or peripheral in origin. Its most frequent 
cause is diphtheria, in which case there is usually associated 
paralysis of other parts. If the epiglottis be involved, the 
symptoms will be an exaggeration of those described under 
" Anaesthesia of the Pharynx," with which it is frequently asso- 
ciated. Food often enters the larynx, and may give rise to 
severe paroxysms of coughing or dyspncea, with subsequent 
implication of the deeper air-passages. If the oesophagus be 
paralyzed, the local symptoms will be difficult or impossible 
deglutition and regurgitation of food. These are usuallv 
followed by loss of flesh, unless the patient be fed artificially. 

When the palatine muscles are paralyzed the voice is nasal 
and thick; food regurgitates through the nose ; the soft palate 
and uvula cannot be elevated, but hang in the median line and 
swing backward and forward during phonation. When one 
side only is affected the corresponding half of the soft palate 
droops ; the other may be in its normal position, but more fre- 



MOTOR CHANGES. 275 

quently the soft palate and uvula are drawn to the non-paralyzed 
side. Sometimes the uvula alone is paralyzed. Relaxation of 
one side of the soft palate has been associated, by Woakes, with 
deafness of the corresponding side. 

Paralysis of the constrictors alone usually indicates a past 
diphtheria or a bulbar paralysis. When present, the chief dif- 
ficulty is in swallowing small, hard particles of food; they 
usually pass but little beyond the dorsum of the tongue, from 
which location it is generally necessary to remove them with 
the finger. Liquids and solids may find their way into the 
larynx. 

Prognosis. — The prognosis is generally good, if occasioned 
by diphtheria ; in fact, Nature mostly restores the lost power 
unaided by medicaments ; but when arising from bulbar paraly- 
sis the patient seldom recovers. In paralysis of single muscles 
the prognosis is usually good. 

Treatment. — The mechanical treatment has been fairly 
outlined when speaking of anaesthesia of the pharynx. Al- 
though remedies are usually sufficient to produce the desired 
change, the use of electricity adds much to the speed and cer- 
tainty of the cure. The constant current is generally the better ; 
the positive pole may be placed on the front of the neck, the 
negative on the affected muscles ; but if this cannot be done, 
the negative may be applied to the outside of the neck, over 
the affected muscles, and the positive pole to the nape. 

The remedies for post-diphtheritic paralysis are given 
under " Diphtheria of the Pharynx and Larynx." 

Chorea of the soft palate is a rare neurosis ; only a few 
cases have been reported. It consists in alternate tension and 
relaxation of the soft palate and uvula. Although this phe- 
nomenon is unattended by any external evidence, there is some- 
times a decided click as the muscles relax, in some cases so 
loud as to be heard at a distance of several feet. The contrac- 
tion and relaxation may manifest themselves in alternate 



276 DISEASES OF THE NOSE AND THROAT. 

"nasal" and resonant tones during speech, and in one of my 
little patients was associated with chorea of the vocal bands and 
some general twitchings. Relief followed the correction of a 
decided hypermetropia, but she did not entirely recover until 
ferrum was prescribed, nearly three months later. Schadle 
( Ann. Univ. Med. Sci., 1889) notes a case in which " the velum 
palati was rapidly raised and lowered, without being made 
entirely tense. At the moment of relaxation of the levatores a 
singular ticking sound was produced, which in a quiet place could 
be heard at a distance of twenty feet." The case was cured by 
the application of the galvano-cautery " to the hypertrophy and 
hyperesthesia of the enlarged inferior turbinated bodies, 
posteriorly." 

Agar., bell., cuprum, hyos., ignatia, and mag. phos. are 
valuable remedies. 



CHAPTER XXIII. 

Tumors of the Naso-Pharynx. 



ADENOID VEGETATIONS OF THE VAULT OF THE PHARYNX. 

Adenoid vegetations were not recognized until 1861, 
although now known to be a frequent hindrance to nasal respi- 
ration of childhood, especially in Europe. We are chiefly 
indebted to Meyer, of Copenhagen, for a knowledge of this 
affection. Its seat is the vault of the pharynx and adjacent 
parts. It is due either to hypertrophy of the follicles of this 
region, or to enlargement of the pharyngeal (Luschka's) tonsil. 

Etiology. — Heredity is the chief etiological factor, but 
many cases can be attributed to the existence of chronic nasal 
catarrhs, exanthemata, deflected nasal septi, and nasal obstruc- 
tions. Adenoid vegetations are often associated with enlarged 
faucial tonsils, thickened half-arches, and a narrow, V-shaped, 
or cleft hard palate, while, at other times, they are evidently in 
close accord with the peculiar diathesis so prone to produce hy- 
pertrophy of the faucial tonsils. As a rule, retrogression occurs 
at a much earlier age in the pharyngeal than in the faucial 
tonsil, and an enlarged lingual tonsil is apt to remain until 
late in life. It is well known that in the lymphatic tempera- 
ment the various glandular structures are apt to be diseased, and 
in this affection, as well, this temperament plays an important 
part. It is often noticed that those conditions which give rise 
to inflammation of the faucial tonsils also induce an attack of 
the same nature in the pharyngeal tonsil. 

Children are the most frequent sufferers from adenoid veg- 
etations ; in fact, the disease generally undergoes spontaneous 
cure as the result of advanced years, and at the age of thirty- 
five the vault of the pharynx is usually smooth, although I have 
seen it rough at seventy. It is not safe, therefore, to rely upon 

(277) . 



278 



DISEASES OF THE NOSE AND THROAT. 



this relief by Nature, for the patient may, in the meantime, lose 
the hearing, facial beauty, purity of the voice, and the natural 
power of nasal respiration ; while the chest may undergo the 
change known as "pigeon-breast," with consequent disease of 
the lungs. 

Pathology. — The condition consists of a veritable hyper- 
trophy of the glandular elements of the naso-pharynx, which 




Fig. 68.— Youthful Physiognomy of Adenoid Vegetations— Mouth-Breathing. 
(From a photograph.) 

are much increased in number and size and with multiplication 
and enlargement of the blood-vessels. The mucosa also under- 
goes catarrhal thickening similar to that found in the nasal 
fossae. Adenoid vegetations are of two varieties, — a soft, or 
papillomatous, and a hard, or smooth. In two of my cases of 
the latter variety the mass enlarged during every severe acute 
attack of nasal catarrh. Associated with enlarged pharyngeal 



ADENOID VEGETATIONS OF THE VAULT OF THE PHARYNX. 



279 



tonsils is nearly always a granular thickening of the pharynx 
and edges of the posterior pillars, the faucial walls are glistening 
and wrinkled, and the uvula is often thrown into circular folds. 

Symptoms. — There is apt to be a thick, glutinous, yellow, 
green, muco-purulent, or bloody discharge. The child or young- 
adult has, as in other nasal obstructions, a peculiar nasal intona- 
tion, such as is noted with chronic nasal hypertrophies ; while 
nasal respiration, if, indeed, air can be forced through the nose 
at all, is very loud. The face presents a pinched appearance, 
lines run from the alse nasi to the corners of the mouth, the 
upper incisor teeth project, and the 
nose is thin, but blunt. The patient 
snores during sleep, and, if nasal respira- 
tion be practically impossible, has con- 
tracted chest, with superficial, labored, 
and hurried breathing. In milder cases 
the symptoms are less marked, though, 
as a rule, the same train of complaints 
exists. Aprosexia is believed, by Mr. 
William Hill, to result from lymphatic 
stagnation, which he bases upon the 
fact that the intra-cranial lymphatics 
pass out of the skull along the course 

of the nerve-sheaths (Key and Retzius) ; enuresis, cephalalgia, 
headache, and asthma are reported complications. 

If the person be sufficiently tractable to permit a posterior 
rhinoscopic examination, the vault of the pharynx will be seen 
to contain a mass of irregular lobular tissue, which may fill the 
entire pharyngeal vault and completely obstruct the outlets of 
the nares posteriorly; or the growth may appear as roundish, 
elongated masses, similar to a bunch of raisins. The color is 
generally duller than that of the normal mucous membrane, and 
the tissues are often covered with a greenish-yellow, dirty, or 
bloody discharge, which, in some cases, forms in crusts on the 
vault of the pharynx, completely hiding the vegetations. If 




.—Aged Physiog- 
nomy op Confirmed Mouth- 
Breathing. 



280 DISEASES OF THE NOSE AND THROAT. 

wiped off, bleeding is apt to ensue, although the surface does 
not appear vascular. The pharynx and nares are usually catar- 
rhally thickened, the pharyngeal follicles large and pale, and, 
as a rule, hypertrophies of the septum and turbinateds co-exist. 
When unable to examine with a mirror, the index finger should 
be passed into the post-nasal region ; if vegetations exist, it will 
come in contact with a soft, easily bleeding, irregular mass, 
resembling a bunch of earth-worms. When introducing the 
finger, force is to be avoided ; on that account insert it directly 
back of the posterior pillar. As soon as the naso-pharynx is 
reached the finger can be easily and quickly brought into the 



mw 




Fig. 70.— Adenoid Vegetations and Hypertrophy of Turbinateds, 
Posteriorly. (From Sajous.) 

median line. Semon prefers to inject a little warm water into 
one nostril ; if it do not stream immediately from the other, 
but pass into the mouth, it is evident naso-pharyngeal obstruc- 
tion exists. 

Prognosis. — If we exclude the defects already enumerated 
as likely to arise, the prognosis may be said to be good. It 
must be admitted that few cases escape the loss of the important 
functions named, unless the hypertrophied structures be reduced 
before confirmation of serious changes. 

Treatment. — Much can be done with remedies, but their 
action is slow and should not be long relied upon if the func- 
tions noted be not improving. Where there is much discharge, 



ADENOID VEGETATIONS OF THE VAULT OF THE PHARYNX. 281 

thorough cleansing will aid the internal medication, and polypi, 
exostoses, etc., should be removed. Mechanical means, therefore, 
constitute a considerable part of the treatment. If medicines fail, 
chromic acid may be applied either in the form of crystals fused 
on a probe or in a saturated solution by means of a small, guarded 
applicator (Fig. 27), aided by a rhinoscopic mirror. Three or 
four applications may be made at each weekly sitting. Little pain 
follows even without the use of cocaine. When the solution is 
used, the cottoned applicator is to be dipped into the solution 
and passed back of the soft palate ; when in position, the acidu- 
lated cotton is to be forced out and pushed firmly against the 
growth. Care must be exercised not to have the cotton so satu- 
rated that the acid will be squeezed out when pressure is ex- 
erted, lest it flow down the throat and cause severe inflammation 
or laryngeal spasm. Glacial acetic, mono-chloracetic, or tri- 
chloracetic acid may also be used with the guarded applicator. 




Fig. 71.— White's Palate-Retractor. 

Electrolysis is slow and usually unsatisfactory, but the 
galvano-cautery point or loop is among the efficient means 
of treatment. If the broad point be used it should be inserted 
cold ; and when in position, as determined by the mirror, the 
current is turned on. When cocaine is used there is little or 
no pain. Three or four points may be treated at each sitting, 
at intervals of four or five days. If the snare be used the loop 
should be passed around part or all of the tumor, if possible, 
otherwise it may simply be brought in contact with the mass and 
made to burn itself into the granulations, as recommended by 
Dr. D. A. Strickler. Too large a growth should not be destroyed 
at once, as blood-poison and death may ensue. It is also im- 
portant not to injure surrounding structures, and to this end, if 
working near the soft palate, it should be held forward with 
a palato-uvula supporter, retractor, or hook. 



282 



DISEASES OF THE NOSE AND THROAT. 



In the absence of the galvano-cautery, the mass may be 
encircled by the cold wire ; the loop should then be slowly 
closed ; otherwise the haemorrhage and pain may be severe. 
The time required in amputation varies from half an hour to 




Fig. 72.— Lcewenberg's Forceps. 

two hours. The loop is usually passed through the mouth ; 
but, in event of a free nasal passage, it may be introduced 
through that channel. 

As a rule, the speediest and easiest methods of dealing 




Fig. 73.— Gottstein's Curette. 



with adenoid vegetations are the following: Forceps, curette, 
scoop, curette finger-tip, and sharpened finger-nail. Curved cut- 
ting or crushing forceps are most useful if the mass be large 
and a general anaesthetic be used. The vegetations are grasped 




-Curette Finger-Tip. 



and cut or torn away in pieces. The haemorrhage is quite pro- 
fuse for a time, but soon subsides. In operating with forceps 
or curette, it is better to have the head lower than the shoulders, 
that the blood may flow out of the mouth or nose. Reaction is 



ADENOID VEGETATIONS OF THE VAULT OF THE PHARYNX. 283 



sometimes severe ; on that account the patient should be placed 
in bed for one or two days, and aeon, or fer. phos. given. As 
acute otitis media with perforation of the membrani tympani 
occasionally follows these operations, measures should be insti- 
tuted looking to the prevention of this : the preceding remedies, 





-Major's Anteroposterior Abenotome. 



aided by daily inflation with a Politzer bag (Fig. 34, page 74), 
usually suffice. 

Iodine (20 grains to the ounce of glycerin), kali bi. (30 
grains to the ounce), and sang. nit. (3 x 
trituration) are good local applications. 

Mouth-breathing is frequently either a 
habit or due to a short upper lip or pro- 
jecting upper teeth, the nose and naso- 
pharynx being free. If the patient cannot 
break himself of this pernicious practice, he 
had better wear a plate at night. This can be made of metal, 
but hard rubber, celluloid, or zylonite is better. It is adjusted 
to fit between the lips and teeth. (See paper by the author, 
Halmemannian Monthly, Dec, 1889, and Trans. Homceo. Med. 
Soc. Pa., 1889.) After the inhibitor has caused pressure- 
recession of the incisor teeth, it should be discarded, lest the 




284 DISEASES OF THE NOSE AND THROAT. 

gums be diseased and the teeth lost from pressure of the posterior 
tips of the instrument. In its place should be worn a soft plate, 
to fit inside and outside of the teeth, the cutting edges resting 
on the thin portion of the plate which holds the sides together. 
This should be made from a dentist's impression of the teeth. 

Therapeutics. 

Ars. alb. — Adenoid vegetations ; pharyngeal hypertrophy 
extending to the Eustachian mouths ; nasal swelling of a dark- 
red color ; and, according to Dr. J. H. Buffum, the " middle 
turbinated bone tumefied, to occlusion of the nostril." 

Calc. phos. has received just credit from Dr. R. T. Cooper, 
who considers it almost a specific. 

Kali mur. — When associated with follicular pharyngitis, 
with white, tough, mucous discharge. 

Sang. nit. " has seemed to be of almost universal benefit 
in cases of hypertrophy of Luschka's tonsil, with hypersemia in 
the vault of the pharynx, and in posterior turbinated hypertro- 
phy with congestion." (Extract from a letter from Dr. Malcolm 
Leal.) I have had excellent results with this remedy and with 
calc. phos., the former locally and internally in the 3 x, and the 
latter in the 30 x or 200 x ; thus often avoiding operations. 

POST-NASAL FIBROIDS. 

Etiology. — Post-nasal fibroids are not usual ; their causes 
are those of fibrous tumors elsewhere ; the same may be said of 
their pathology. They are sometimes associated with sarcomata, 
enchondromata, etc. They are rare in females, and usually occur 
between the thirteenth and twenty-third years of life. Post- 
nasal fibroids are usually thickly pedunculated and spring from 
either side of the basis cranii, never ( 1 ) from the middle, and 
from the upper cervical vertebrae. Their invading characteristics 
have been noted under " Fibroid Tumors of the Nose." 

Symptoms. — The symptoms depend much upon the size of 
the growth. At times the only complaint is of difficult nasal 



FIBRO-MUCOUS POLYPI. 285 

respiration, but usually haemorrhages are frequent and profuse ; 
the discharge thick, gluey, and ropy, or bloody and fetid from 
ulceration; headache and neuralgia result from pressure; deg- 
lutition and speech defects arise from pharyngeal extension ; and 
even grave mental symptoms, varying from aprosexia to loss of 
memory, are occasionally observed. The pressure which they 
exert may be so great as to break down the bones in any direc- 
tion, giving rise to deformity or brain-lesion and death. Gron- 
bech (Ann. Univ. Med. Sci., 1889) found cases of sudden death, 
during the course of nasal and post-nasal fibroids, due to fatty 
degeneration of the heart. 

Diagnosis depends upon the preceding symptoms ; the 
hard, fibrous character of the tumor ; its smooth, glistening, often 
lobulated appearance ; and the youth of the patient. 

Prognosis. — The prognosis is grave, in the main ; it was 
formerly looked upon as universally so, owing chiefly to the 
radical measures adopted. Even yet patients may die as the re- 
sult of haemorrhage, cranial involvement, pyaemia, exhaustion, 
or neglect of treatment. The growth may be self-limiting or it 
may degenerate. 

Treatment. — The treatment is chiefly mechanical : electroly- 
sis, galvano-cautery, and the cold snare are indicated in the 
order named. Where possible, the more formidable operations 
are to be avoided as too dangerous. When using the galvano- 
cautery, the steel wire, as pointed out by Dr. W. A. Dunn 
(The CHnique, March, 1890), is to be preferred to platinum, as 
less likely to cause severe haemorrhage. (See treatment of 
" Fibroid Tumors of the Nose.") 

FIBRO-MUCOUS POLYPI. 

Fibro-mucous growths of the naso-pharynx are much more 
frequent than the preceding, and, unlike them, they occur chiefly 
(in my experience, only) in females. These polypi occur singly, 
are pedunculated, attached near the edges of the choanae, and 
rarely show a tendency to recur after removal. 



286 DISEASES OF THE NOSE AND THROAT. 

Symptoms. — The symptoms are not characteristic, and con- 
sist of a sensation of a foreign body ; perhaps alternate nasal 
obstruction, owing to mobility of the polypi ; and interference 
with deglutition and articulation. Inspection reveals a long, 
teat-like mass extending from above. It is nearly the color of 
the uvula, but usually somewhat duller. Palpation detects an 
elastic, movable mass. The prognosis is good. 

Treatment. — Relief must be mechanical. Jarvis' or Sajous' 
curved-tipped snare is usually sufficient, but care must be exer- 
cised that the wire do not break ; in one case 
in which this repeatedly occurred, I severed 
the growth with a pair of curved scissors, not 
having a galvano-cautery at hand. 

At times forceps (see "Adenoid Vegeta- 
tions of the Vault of the Pharynx") are the 
best instruments to use. 



ENCHONDROMATA. 

Five cases of this rare neoplasm have been 
reported. In some of these external opera- 
tions were performed ; but in my patient (see 
Hahnemannian Monthly, June, 1891) the 
DwS^AoSasSe almost white growth was removed by curved 
(From a photograph post _ nasal f orceps , leaving no trace of its 

pedicle, which was adherent to the upper rim of the right 
choana. The prognosis is good and the treatment chiefly 
mechanical. 

MALIGNANT TUMORS. 

Sarcomata and carcinomata of the naso-pharynx are rare. 
They occasion obstruction and often pain, haemorrhage, and 
fetid discharge. The surrounding tissues are frequently invaded, 
impairing the function of the affected part. The cervical glands 
may enlarge in both classes, but this change occurs earlier in 
carcinoma. Pain usually extends to the ears. A broad-based, 
easily-bleeding, soft, ulcerating tumor in a person over 30 years 




MALIGNANT TUMORS. 287 

of age is usually malignant ; fibromata occur earlier, and are 
much harder and more denned in outline, yet sarcomata occa- 
sionally occur in youth. The prognosis is grave, although 
sarcomata are sometimes cured by removal. (For other treat- 
ment, see " Malignant Tumors of the Pharynx.") 



CHAPTER XXIV. 

Uvular and Tonsillar Diseases. 



Diseases of the Uvula. 
As most uvular affections are associated with similar con- 
ditions of the pharynx, they need no separate mention ; but 
since there are some diseases which centre in this appendage, 
the surrounding tissues being but slightly affected, they deserve 
special consideration. 

UVULITIS. 

Acute inflammation of the uvula is occasionally met as an 
independent disease. The uvula is reddened, swelled, and 
elongated. Although the mucous covering is usually tense and 
often glistening, it is not transparent, as in oedema. The 
symptoms and prognosis are so similar to those of oedema of 
the uvula that they will be found there. Aeon., bell., caps., 
fer. phos., mere, sol., and mix vom. are the chief remedies. 

ACUTE INFLAMMATORY CEDEMA OF THE UVULA 

Etiology. — Although comparatively infrequent, this affec- 
tion is sometimes observed as the result of cold, gastric disorder, 
rheumatism, erysipelas, syphilis, phthisis, general dropsy, and 
traumatism. 

Symptoms. — There is usually a sense of fullness in the 
throat, a foreign substance upon the tongue, difficult deglu- 
tition on account of food passing through the nose, a frequent 
desire to swallow saliva, a slight amount of pain, and very 
thick, indistinct articulation. Cough and irritation, such con- 
stant accompaniments of chronically relaxed uvula, are rarely 
prominent in acute oedema. The uvula is congested, thickened, 
and dropsical, resembling a bag of water, the effusion often 
being very pronounced. 
(288) 



RELAXED UVULA. 289 

The prognosis is good, although chronic relaxation may 
follow. 

Treatment. — The treatment is usually very simple, and the 
results prompt and satisfactory. It is generally advisable to 
hold a solution of alcohol (1 part) and water (4 parts) in the 
mouth for a few minutes several times daily. It is occasion- 
ally necessary to puncture, but never to amputate, the uvula. 
Tannate of glycerin (1 to 30) is grateful. 

TJierapeutics. 

Apis. — Uvula very cedematous, like a bag of water, but 
little inflammatory redness ; right side more involved. 

Ars. — General cedematous complication, weakness, thirst. 

Caps. — Elongated, relaxed, cedematous, inflamed uvula; 
enlarged and painful cervical glands. Left side shows the 
force of the infiltration, with dusky redness of the uvula and 
adjacent palatine arches, and considerable burning in the 
affected parts. 

Kali bi. — (Edema with syphilis or with pseudo-membranous 
diseases ; characteristic stringy, ropy discharges. Ulceration of 
uvula. 

Kali iod. — (Edema with or without syphilis ; thin, acrid 
expectoration. 

Rhus tox. — The tip of the uvula looks like a drop of fluid 
or jelly; especially in rheumatic subjects or during erysipelas. 

RELAXED UVULA. 

Etiology. — This condition is generally associated with 
relaxation of the soft palate. Its causes are similar to those 
giving rise to chronic pharyngitis, including disordered stomach 
and liver, overuse or strain of the voice in throaty speech or 
song, severe coughs, tobacco, and chemicals. Heredity seems 
to play some part in the production of relaxed uvula. It not 
infrequently appears without ascertainable cause. The uvula 
is long (" falling of the palate ") and usually quite thin, although 



290 DISEASES OF THE NOSE AND THROAT. 

occasionally thick. The patient can frequently elevate the 
muscular and contiguous parts, while the lower portion of the 
mucous lining hangs in a " string " and rests upon the base of 
the tongue ; it often happens, however, that there is inability to 
raise any portion of the appendage, which touches and irritates 
the pharynx and epiglottis. 

Symptoms. — The symptoms are by no means characteristic, 
but consist of frequent efforts to swallow and clear the throat ; 
irritable or paroxysmal cough, worse when lying; retching and 
vomiting ; and reflex spasm of the larynx, arousing the patient 
from sleep. As a result of these symptoms, the general health 
may suffer ; the patient become nervous, irritable, sleepless ; the 




Fig. 78.— Sajotjs' Uvula-Scissors. 

appetite may fail, and digestion suffer, with resultant loss of 
flesh, — simulating phthisis. Finally, the singing voice may be 
greatly impaired, and effort, fatigue, and tremulo accompany 
vocalization. When vocal defects are prominent, however, 
the soft palate is generally relaxed as well. If cough be a 
prominent symptom, the laryngeal mucous membrane is com- 
monly somewhat congested in consequence. 

The prognosis is good. 

Treatment. — Surgical interference is sometimes required. 
Locally, a solution of chloride of zinc, alum, or tannin (15 
grains to the ounce of glycerin) may be applied or used as a 
gargle. Faradism and galvanism are of importance. If failure 



TUMORS OF THE UVULA. - 291 

ensue after a fair trial of internal remedies, together with these 
adjuvants, the lower end of the uvula should be amputated. 
Only the mucous membrane is to be removed, unless there be 
great redundancy of tissue. Although numerous uvula-tomes 
have been devised, none of them seem more efficient than a 
pair of uvula-scissors and long, slender forceps, with which the 
tip of the uvula is grasped and held, but not drawn upon, while 
the scissors are in use. Very little pain is occasioned, although 
cocaine may be used if desired. " After-pain " is sometimes 
considerable, and may require staphisagria internally and pieces 
of ice or iced water locally. The patient should use his voice 
gently for a day or two, and for several days should not eat very 
hard or highly-seasoned food. 

Remedies are to be prescribed chiefly upon the constitu- 
tional condition ; but apis, caps., chlor. zn., and tannic ac. are 
indicated pathologically. 

Therapeutics. 

Calc. fluor. — Relaxed uvula, when the tickling is referred 
to the larynx. 

Hyos. — Cough from relaxed and elongated uvula. This is 
the one remedy upon which I place dependence, in such cases, 
where there are essentially no other symptoms and when there 
is no inflammation of the pharynx. 

Ignatia is similar to hyos., but the tonsils or cervical glands 
are generally enlarged. 

Pulsation of the uvula and faucial region is sometimes 
noticed in aortic insufficiency, as pointed out by F. Midler, of 
Berlin, and P. Merklen. 

TUMORS OF THE UVULA. 

Warty (syphilitic or non-specific) and angeiomatous growths 
occasionally spring from the uvula. 

The symptoms are similar to those noted under " Relaxa- 
tion of the Uvula." 



292 DISEASES OF THE NOSE AND THROAT. 

The treatment is by abscission, if large enough to occasion 
marked annoyance, although the galvano-cautery is to be pre- 
ferred for small or vascular growths. Ars., ham., sang, nit., and 
thuja are indicated internally. 

Diseases of the Tonsils. 

acute tonsillitis — quinsy. 

Children and young adults are those most frequently 
attacked by quinsy. It is not very usual before the age of ten 
or twelve, but from that time to twenty it gradually grows more 
frequent; at the age of thirty it is unusual, and rarely occurs 
after fifty. Acute tonsillitis is more frequent in men and boys 
than in women and girls, chiefly on account of the greater ex- 
posure to which the former are subjected. It is a common dis- 
ease in nearly all climates, though vastly worse in those that are 
changeable. Recent research favors the idea of its infectious 
nature. 

Etiology. — It has as causes exposure to cold or draughts of 
air, particularly when the body is overheated and the system at 
a low ebb, impure air, imperfect drainage, rheumatism, gout, etc. 
Highly-strung, nervous temperaments, anaemic and delicate per- 
sons furnish frequent examples of acute tonsillitis. Shock, fright, 
mental emotions, heredity, scrofula, and syphilis are undoubted 
etiological factors. Traumatism (hot water, caustics, etc.) acts 
as an exciting cause ; chronic enlargement of the tonsils and 
former acute invasions act as predisposing factors. Scarlatina, 
measles, typhoid fever, small-pox, and malaria may induce 
secondary tonsillitis. Finally, no assignable cause can be found 
for many cases. 

Varieties. — One tonsil may be alone affected, or one before 
the other. When they are affected simultaneously, the disease 
is usually septic in origin. Acute tonsillar inflammation may 
attack a tonsil when in an apparently healthy condition, or it 
may involve an already hypertrophied gland. Although the 



ACUTE TONSILLITIS — QUINSY. 293 

force of the disease is generally centred in the tonsil, neighbor- 
ing structures are affected later and often to a considerable 
degree, or the inflammation may be chiefly confined to the tis- 
sues surrounding the tonsil (peritonsillar inflammation), usually 
the result of septic poison. The superficial portions of the 
gland may be alone involved (erythematous tonsillitis) ; the 
parenchyma may be affected throughout (parenchymatous 
tonsillitis), often leading to pus formation (quinsy proper) ; 
or the lacunae may be chiefly diseased (follicular, or lacunar, 
tonsillitis). The inflammatory process ends either in resolution 
(the usual termination), abscess formation (much less frequent), 
or imperfect resolution leading to chronic enlargement (inter- 
mediate in frequency). Some have described a subacute form, 
but this seems to correspond to the erythematous variety. 
Acute follicular tonsillitis is so distinct as to require separate 
consideration. 

Symptoms. — The symptoms depend much upon the stage 
and severity of the attack. In the milder form as well as in 
the deeper-seated malady, the first symptoms may be malaise, a 
slight chill, headache, pain in the neck and back, a soreness, 
tenderness, fullness or pain in the region of the fauces, stiffness 
on swallowing, and swelling and tenderness of the glands in the 
cervical region at the angles of the jaw. In severe cases there 
is decided chilliness, perhaps a rigor, and a rise of temperature. 
In mild cases the mercury registers 100° to 101° F. ; but in 
those more severe, 103° to 105° F. ; the pulse is correspond- 
ingly quickened. In a few hours the pain becomes severe ; it 
is difficult or impossible to open the mouth ; deglutition is diffi- 
cult, painful, or impossible; and fluids, or even food, may 
regurgitate through the nose or pass into the larynx. 

As a result of exudation oedema of the uvula, pharynx, 
or larynx may supervene. The voice is thick, dull, almost 
suppressed, and its production is attended by considerable 
effort ; articulation may be greatly affected and speech even be 
rendered unintelligible. Pain in the region of the tonsil is 



294 DISEASES OF THE NOSE AND THROAT. 

often so great as to prevent sleep, and usually shoots to the 
ears during deglutition ; on account of inflammatory extension 
to the Eustachian tubes, pressure of the enlarged tonsils upon 
the palato-glossus muscles, or infiltration pressure on the mouths 
of the Eustachian tnbes. Temporary deafness is not an infre- 
quent complication, owing to inflammatory, serous, or purulent 
involvement of the middle ear ; the patient snores ; his senses 
of smell and taste are defective ; and his respiration is often 
greatly hindered. There is a continual secretion of thin mucus, 
attended by an almost constant desire to swallow, but which is 
resisted, as it causes agonizing pain, under which the victim 
cringes. As a consequence, the head is thrown forward and 
the mouth kept open much of the time, that the saliva may 
dribble from it. In less severe cases the saliva is expectorated 
with difficulty. Rotation of the head often occasions intense 
pain, both in the head and throat, so that the patient moves the 
entire body rather than the head alone. 

General prostration and headache are prominent symptoms. 
The tongue is nearly always heavily coated with a white deposit, 
and takes the imprint of the teeth; the breath is very offensive, 
and, as the mouth is so difficult to open, the diagnosis often has 
to be made from the symptoms already given. Usually, how- 
ever, it is possible to peep into the faucial region, when one or 
both tonsils will be seen greatly enlarged, even meeting in the 
median line, the uvula cedematons, the half-arches swelled, the 
mucosa inflamed and bright red or dusky in color. The 
pharynx is red, perhaps infiltrated, or covered with a whitish 
mucus, which may be mistaken for a diphtheritic deposit, espe- 
cially if it appear upon the tonsils. In diphtheria the dis- 
charge cannot be wiped off readily and leaves a bleeding sur- 
face which is re-coated within twelve hours, but the much less 
pain, the lower temperature, and the albuminous urine are to 
be chiefly relied upon as indicating diphtheria. Sometimes the 
crypts are blocked with a slight secretion. 

If pus be present there is a throbbing, lancinating pain, 



ACUTE TONSILLITIS QUINSY. 295 

and the tonsil has a boggy appearance, or even a yellowish point- 
ing. Fluctuation may sometimes be detected by the finger or 
probe. When it is impossible for the patient to open his mouth 
sufficiently wide to permit a view, the finger can sometimes be 
thrust into it in order to feel what cannot be seen ; but as this 
is a very painful procedure, gentleness is important. Although 
the ordinary symptoms of fever, thirst, heat, nausea, restless- 
ness, constipation, high-colored urine, etc., may characterize the 
ordinary case, when the temperature reaches 103° F. or more, 
there may be delirium and albuminuria, but no tube-casts. 

Should the disease subside by resolution, all the symptoms 
gradually abate ; when the termination is by abscess, the latter 
bursts, if not previously opened, giving such prompt relief that 
the patient often at once falls into a gentle sleep. In the 
majority of cases the purulent collection is so slight that its 
evacuation is not attended with any troublesome symptoms, the 
pus being either expectorated or swallowed during sleep ; occa- 
sionally, however, it flows into the larynx and results in serious 
dyspnoea, in rare cases even in death. Erosion of the carotid 
artery has given rise to rapidly fatal haemorrhage. Should the 
condition end in imperfect resolution, the acute symptoms grad- 
ually subside, leaving a sensation of fullness in the region of 
the recently inflamed and still enlarged tonsil. If there be 
laryngeal dyspnoea, oedema may be suspected. 

Diagnosis. — The differential diagnosis is rarely difficult, but 
quinsy may be confused with diphtheria (as already given), 
follicular tonsillitis, membranous pharyngitis, phlegmonous 
pharyngitis, scarlatina, and erysipelas. 

Follicular tonsillitis is distinguished by the little dots of 
whitish deposit which, when wiped or pulled upon by forceps, 
are seen to be continuous and adherent to such a secretion 
extending into the lacunae ; there is not so much alteration of 
voice or difficulty in opening the mouth ; and the tongue is less 
coated. 

Membranous pharyngitis rarely has any glandular involve- 



296 DISEASES OF THE NOSE AND THROAT. 

ment ; the tonsils are seldom acutely enlarged ; the membrane 
is generally found on the pharynx as well as the tonsils; 
and there is neither the difficulty in opening the mouth nor the 
characteristically coated tongue. 

Phlegmonous pharyngitis is to be distinguished, chiefly, by 
the more extensive involvement of the pharynx and the greater 
amount of peritonsillar inflammation ; although Cohen looks 
upon them as one affection. 

Haig-Brown considers it important to note the time of 
the appearance of the albumin. If it " be found for the first 
time on the second or third day, the temperature being at 103° 
F. or more, and disappear on the fourth, we are almost surely 
dealing with a case of simple tonsillitis ; if, however, we find 
albumin in the early days, with a comparatively low tempera- 
ture (100° to 101° F.), and especially if the albumin persist for 
two or three weeks, the case is most likely one of diphtheria ; 
while, if there have been no albumin early, and it be found for 
the first time after the end of two, three, or more weeks, it is 
most probable that the case has been one of latent scarlatina." 
Lennox Browne places much reliance upon a glandular enlarge- 
ment at the angle of the jaw in scarlet fever, and its absence in 
simple tonsillitis. 

Scarlatina without eruption is to be recognized by the 
higher fever, the flushed face, the dilated pupils, the "straw- 
berry tongue," the urinary change noted, and the enlargement 
of the gland at the angle of the jaw. 

Syphilis, primary cancer of the tonsil, measles, and post- 
diphtheritic and labio-glosso-laryngeal paralysis, although bear- 
ing some resemblance to tonsillitis, are readily distinguished, 
either by inspection or by the history of the case. 

Prognosis. — The prognosis is usually good ; the affection 
rarely lasts longer than from five to ten days, although the 
second tonsil sometimes suffers after recovery of the first. A 
chronic abscess or a cyst occasionally persists after subsidence 
of the acute inflammation. Rare instances are recorded of pus 



ACUTE TONSILLITIS — QUINSY. 297 

burrowing into the mediastinum, infiltrating the tissues of the 
neck, causing erosion of the carotid and maxillary arteries, or 
fatal oedema of the larynx. The attack may alternate with a 
rheumatic seizure. 

Treatment. — If seen early enough, it is frequently possible 
to abort the attack. If the pain and dysphagia be very great, 
steam inhalation is often comforting as well as curative ; but as 
fatigue soon occurs the inhalation should not be continued 
longer than from five to ten minutes. It is often advisable to 
impregnate the steam with some soothing drug, — eucalyptus, 
for example. Pieces of flannel may be wrung out of hot water 
and laid over the tonsillar region. In the early stage, the pa- 
tient may find it comforting to hold in his mouth (or gargle) 
hot milk alone or combined with guaiacum (1 drachm to the 
ounce), warm water and glycerin (2 to 1), lemonade, lime- 
juice, etc. On account of dryness of the throat it is well to 
have the atmosphere of the room moistened, either by means of 
the atomizer, spray, boiling water, or a hot brick or iron im- 
mersed in a bucket of cold water. If at all positive of the pres- 
ence of pus, the tonsil should generally be incised: (1) to 
relieve the pain and (2) to obviate any serious danger of flood- 
ing the larynx by evacuation of the abscess during sleep. Here, 
as in opening a retro-pharyngeal abscess, it is better, if the pus 
be abundant, to have the patient's head thrown forward before 
incising. The knife should be inserted into the gland with its 
cutting-edge turned toward the median line, and care must be 
exercised not to wound the half-arches. If the abscess form on 
the upper edge of the tonsil it is better to puncture rather than 
cut, lest the soft palate and posterior pillar of the fauces be in- 
jured. It is usually safer to use a pair of rather blunt-pointed 
scissors. Some advocate early incision in order to relieve pain, 
swelling, and dysphagia. Internal remedies, however, aid evac- 
uation and often relieve the patient from the fear of the lance. 
Locally, bicarbonate of soda occasionally relieves, but W. It. 
King prefers equal parts of the bicarbonate and the biborate, 



298 DISEASES OF THE NOSE AND THROAT. 

with the addition of 4 grains of iodoform to the ounce of the 
former combination. He has seen this result in speedy evac- 
uation. 

Prophylactic treatment consists in the administration of 
good, nutritious, non-stimulating food. Pastry and sweatmeats 
should be avoided. Fresh air, exercise, and the daily salt-water 
sponge-bath, with subsequent friction, are important considera- 
tions. As constipation adds to the possibility of recurrence, 
this should be properly cared for ; and wet feet, exposure to 
draughts, and impure air are to be avoided. 

The best abortive remedies are baptisia, baryta carb., 
guaiac, and kali iod. 

Therapeutics. 

Apis. — Stinging, burning when swallowing; oedema of 
uvula and half-arches, the left tonsil the worse. The super- 
ficial tissues are alone involved (bell, affects the parenchyma). 

Baryta carb. — Tendency to suppuration, especially of right 
side, in tonsillitis from suppressed foot-sweat ; muscular paresis. 
C. Hansford {Horn. World, June, 1882) records several cases in 
which this remedy in the twelfth cured very promptly, even 
when the patient was scarcely able to swallow and with threat- 
ened pus formation ; it is useless after pus has formed. 

Bell. — Bright-red, especially right, tonsil ; swelling and 
tenderness of neck and anterior cervical glands ; deglutition 
of liquids especially painful. 

Calc. sulph. — When suppuration occurs or is threatened, 
and in place of hepar. 

Caps. — Serous infiltration of the faucial tissues; boggy, 
not oedematous, in appearance ; left side worse ; pain burning, 
stinging. When the tongue is heavily coated white, uvula 
oedematous, especially with a dusky infiltration of the left pillars 
and some swelling of the lymphatic glands, caps., in the 3 x or 
6 x, will usually relieve inside of twenty-four hours. 

Colch. — When associated or alternating with rheumatism ; 
throat dry, with free discharge of saliva from the mouth. 



ACUTE FOLLICULAR, LACUNAR, SIMPLE TONSILLITIS. 299 

Guaiac. — Threatened tonsillitis, violent burning in throat. 
This remedy in the 1 x frequently repeated often seems to abort 
the attack. 

Hepar. — With the sticking pains, chilliness, and rigors in- 
dicative of on-coming suppuration, and later to assist evacuation; 
according to personal experience, preferably in the 2 x in either 
case. Pains shoot into the ears. Aggravation from draughts, 

Merc. sol. — Parenchymatous form (after bell.); throbbing, 
stinging pains ; thin, pseudodeposit on tonsils and pharynx ; 
flabby and tooth-indented tongue ; marked ptyalism ; pain on 
empty swallowing ; hastens pus formation and evacuation. 

Phytol. — Chills and fever alternate; prostration; pain run- 
ning to ears on deglutition ; affected parts dark-purple, almost 
blue ; rheumatic subjects ; uvula enlarged and cedematous. 

Silica. — Especially left side, when suppuration seems long 
pending ; also for long-continued suppuration ; deep ulcers, 
even gangrene. Deglutition causes severe pain. 

Sulph. — Slow reaction to treatment ; slow decline of irrita- 
tion after discharge of pus. 

ACUTE FOLLICULAR, LACUNAR, SIMPLE TONSILLITIS. 

Etiology. — The causes of acute follicular tonsillitis are 
similar to those of the forms just considered. There seems to 
be little doubt that it is infectious. Entire families occasionally 
suffer, either as a result of this influence or of insanitary sur- 
roundings. 

Pathology. — Pathologically, it consists in a fibrinous exu- 
dation from the lacunar lining, which makes its appearance at 
the mouths of the crypts, from which it may extend and cover 
considerable areas of one or both tonsils and even adjacent 
structures, thus simulating a false membrane. 

Symptoms. — The symptoms are similar to those of the 
parenchymatous variety, but, though there is less fever, there is 
usually greater pain in the back, joints (rheumatic 1), and the 
prostration is more marked ; the tongue is not so heavily coated, 



300 DISEASES OF THE NOSE AND THROAT. 

and the papillae stand out more boldly (white-strawberry 
tongue) ; deglutition is not so painful ; the glandular enlarge- 
ment is less ; and there is little difficulty in opening the mouth. 

As complications (C. W. Haig-Brown, Wm. Osier, and 
others), are to be noted : Endocarditis, valvular disease, rheu- 
matism. 

Diagnosis. — The diagnosis (see " Diphtheria of the Pharynx 
and Larynx ") is rarely difficult after the appearance of the exu- 
dation ; previous to that time, however, the disease should not 
be named. It seems, occasionally, to precede diphtheria. When 
the spots first appear, the tonsils are studded with little white 
points ; white patches form later ; these can be wiped off, and, 




Fig. 79.— Acute Follicular Tonsillitis. 



if carefully watched, will be seen extending into the crypts of 
the tonsils. If grasped with a pair of forceps and pulled upon, 
they will be seen to come in a string directly from the mouths 
of the lacunas, into which a probe can usually be passed to a 
considerable depth. The tonsil proper is often little enlarged. 
Occasionally the pharyngeal follicles participate in a similar 
process and give rise to a slight deposit. Dr. Jacobi thinks this 
condition, in reality, pure and simple diphtheria {Jour. Lar. and 
R7iin., July, 1891). 

Prognosis. — The prognosis is good. The duration of the 
disease is from ten hours to three or four days. It rarely 
becomes chronic unless complicated by parenchymatous altera- 
tions. Its association with diphtheria should be remembered. 



ENLARGED (HYPERTROPHIED) TONSILS. 301 

Treatment. — The treatment should be chiefly medicinal. 
Adjuvants should consist of steam inhalations, hot-water gar- 
gles, or pieces of ice. In general, it is better to isolate the 
patient until the exudation has disappeared. 

Apis and ignatia, if given early, stand side by side as 
specifics ; but, at a later date, mere. iod. rub. acts better, and 
benzoate of soda often materially assists. 

Therapeutics. 

Apis. — Numerous points of beginning follicular secretion ; 
cedema of the uvula and half-arches, deep lacunar ulceration. 
Follicular secretion resembling pseudomembrane. Clinically, 
apis is almost a similimum. 

Ignatia. — Tonsils studded with small, superficial, yellowish- 
white ulcers ; plug in the throat, worse when not swallowing ; 
swelling of cervical glands. 

Lach. — Tonsils swelled and livid-looking when dots appear. 

Merc. iod. rub. — This is the favorite remedy with many 
practitioners, but clinical experience places apis and ignatia far 
in the lead. 

ENLARGED (HYPERTROPHIED) TONSILS. 

Etiology. — Enlarged tonsils occur most frequently in chil- 
dren and young adults. As with acute tonsillitis, the chronic 
change grows less frequent after the age of thirty, and many 
children lose their tonsillar enlargements at puberty ; after the 
age of forty it is unusual to see much of the tonsils beyond the 
confines of the half-arches (see Fig. 56, page 152). The con- 
dition is generally the result of imperfect resolution of acutely 
inflamed tonsils, although the enlargement sometimes seems to 
be chronic from the start, there being no apparent cause for it. 
It may be stated, however, that an attack of measles, scarlatina, 
or diphtheria may be so severe as to cause the tonsillar inflam- 
mation to be entirely overlooked, thus giving no history of the 
original cause. The changes at puberty, syphilis, phthisis, 
rheumatism, indigestion, scrofula, imperfect hygiene, etc., are 



302 DISEASES OF THE NOSE AND THROAT. 

occasional causes. As the tonsillar enlargement is sometimes 
augmented during the menstrual period, there may be a closer 
association between these glands and the sexual sphere than is 
generally conceded. 

Pathology. — The pathological changes consist of a thick- 
ening (1) of the cellular elements of the tonsils (soft enlarge- 
ment), (2) of the intercellular structures (hard or scirrhous 
hypertrophy), or (3) a collection of retained secretions in the 
lacunae of the glands (hyperplasia or chronic lacunar tonsillitis), 
in which the mouths of the crypts are often everted and the 
tonsil very ragged, owing to destruction of portions of the 
gland. The tonsil proper may appear little enlarged owing to 
destruction of its parenchyma. Frequently, the hypertrophy 
is composed of two portions (one above the other), separated 
by a simple fissure in which concretions or pellets of solid secre- 
tion may sometimes be found, — the nidus of a pharyngeal or 
laryngeal irritation and reflex cough. The tonsillar mass is 
often firmly adherent to the half-arches or to the lateral pharyn- 
geal wall ; such adhesions frequently give rise to much irritation 
and impair muscular action, especially during vocalization. 
Directly below the normal tonsils is a number of glands, im- 
perceptible in the normal throat, which sometimes enlarge and 
give rise to considerable annoyance, chiefly by producing aching,, 
painful deglutition and cough. 

The tonsils, if normal, are seldom visible, but as soon as 
decidedly augmented in volume they come into view. They 
may project but a short distance beyond their beds, or be so 
large as to press against the uvula, or even unite in the median 
line and almost prevent the passage of food and air. They may 
be smooth or very ragged and with depressions on their surfaces, 
the result of former ulcerations or abscess formation. In chronic 
lacunar tonsillitis, a cheesy material exudes from the crypts; 
if a curette be passed into the openings, an offensive, caseous 
mass may be dislodged ; it may, however, become solid and 
result in a calcareous concretion. Occasionally, the gland is 



ENLARGED (HYPERTROPHIED) TONSILS. 303 

very small, when lacunar tonsillitis can only be discovered by 
drawing the palato-glossal fold forward by means of a bent 
retractor or probe ; more frequently the tonsil is quite large, 
and, when emptied of its contents, collapses. Irritation of the 
pharynx and larynx is not a very unusual sequel of enlarged 
tonsils, especially if they contain marked accumulations. The 
impairment of digestion, appetite, respiration, and sleep often 
leads to constitutional disorders. 

Symptoms. — Symptomatically, it is necessary to consider 
both the local and the remote effects. If the gland or glands be 
much enlarged there will be a sensation of fullness ; but when 
small, the symptoms are not especially noticeable and are often 
overlooked. The voice is generally " nasal," thick, without the 
proper timbre, and produced with evident effort. There is no 
hoarseness unless the vocal bands be affected. Reflex spasmodic 
cough is not usual, but may occur. Taste, smell, and hearing 
are frequently impaired; the latter not from direct tonsillar 
pressure upon the Eustachian 01'ifices, but from an hypertrophic 
or catarrhal involvement of the tubes and their mouths; although 
the tonsillar pressure may impair the free action of the palato- 
tubal muscles. The pharyngeal tonsil is frequently enlarged, 
and interferes with tympanic aeration. Difficulty in deglutition 
often causes great inconvenience to the patient, who is usually 
obliged to drink much during meals in order to aid the passage 
of solid food. The hindrance to nasal respiration is often 
augmented by hypertrophy of the Schneiderian membrane and 
partial collapse oif the alse nasi ; as a result, there is often im- 
perfect aeration of the blood, collapse of the air-cells, bronchitis, 
lack of development in the lung-tissue, and sinking in of the 
chest-walls, giving rise to the deformity known as " pigeon- 
breast." The patient snores much during sleep and breathes 
heavily while awake. 

In any form of enlarged tonsils, acute inflammation is apt 
to occur and be attended by the ordinary symptoms and followed 
by an increase of tissue. 



304 DISEASES OF THE NOSE AND THKOAT. 

The detrimental effect of enlarged tonsils upon the voice 
is chiefly due to interference with the free action of the pharyn- 
geal and palatine muscles, preventing that nice adjustment of 
muscular power so essential to perfect intonation and the direc- 
tion of the tone to the proper sounding or resonant point. 
These conditions are of vital importance to easy tone production 
and a pure timbre. Add to this the loss of the nasal resonator 
as a result of obstruction, and some of the vocalist's difficulties 
may be appreciated. 

Prognosis. — The prognosis is good if the tonsil be reduced 
before marked complications arise. The hindrance to respira- 
tion may result in serious changes, lack of development of the 
chest and lungs in early pulmonary disease, and implication of 
the nose in permanent deformity, hypertrophy or relaxation of 
the walls of that organ, post-nasal catarrh, enlarged pharyngeal 
tonsil, Eustachian catarrh, and deafness. The hypertrophy may 
suddenly disappear after a severe acute illness, chiefly diphtheria 
or scarlet fever. 

Treatment. — Remedial treatment is to be recommended in 
every case ; unfortunately, it is not usually followed by prompt 
tonsillar reduction, although the collateral symptoms and general 
health improve. Careful hygienic and dietetic regulations add 
much to the force of the remedies. The patient should have 
good, nourishing food and plenty of fresh air and exercise, such 
as boating, tennis, cycling, gymnastics, etc. If the neck and 
chest be bathed, as directed under " Chronic Pharyngitis," and 
a flesh-brush or English horse-hair gloves and strap be per- 
sisted in for a time, the acute invasions will grow less frequent 
and severe, the local circulation improve, and the neighboring 
glands decrease in size. 

If these means fail, local measures should not be withheld. 
One of the following methods may be employed, according to 
the severity of the case, the condition of the tonsil, etc. ; if 
the latter be irregular and the crypts open, it is usually best to 
use chromic acid or the galvano-cautery. In using the former, 



ENLARGED (HYPERTROPHIED) TONSILS. 



305 



one or two crystals are to be fused on the end of a heated 
probe and introduced into the little crypts every four or five 
days for a few weeks. When using the galvano-cautery, the 
point should be brought near the crypt to be entered, the circuit 
completed, and the point thrust into the opening ; it should be 
removed while hot, in order to avoid unnecessary pain. Two 
or three lacunae are thus treated at a time. A 4-per-cent solu- 
tion of cocaine may be first brushed over the tonsil in order to 
prevent the slight pain that otherwise arises. The reaction is 
slight and the treatment may be repeated in five days. This is 




Fig. 80.— Mackenzie's Tonsillotome, as Modified by Mandeville. 



usually the most satisfactory method of treating lacunar ton- 
sillitis, but, if there be " bridges " of tissue which prevent the 
free exit of the caseous mass, they should be divided by the hot 
blade or torn through with a probe, and all cavities emptied by 
a small scoop or curette. 

The practice of injecting a few drops of glacial acetic or 
carbolic acid into hypertrophied tonsils is painful and not very 
satisfactory. Electrolysis needles may be used, but the results 
appear slow. 

When the tonsil is rather smooth and firm, excision with 



306 DISEASES OF THE NOSE AND THROAT. 

the tonsillotome is to be advised ; even when it is very uneven 
this method is often best, as time and annoyance are thereby 
saved ; but patients and parents often object to the knife, thus 
necessitating other measures. Tonsillotomy is almost painless, 
and is attended with very little risk, although serious conse- 
quences have been reported, the sequence of removing too 
much of the gland, of a " bleeding habit," or of an anomalous 
position of the artery. It is impossible to wound the internal 
carotid with a guillotine, as the artery lies back of the tonsil at 
the side of the pharynx ; any serious arterial haemorrhage, most 
probably, arises from the tonsillar or ascending pharyngeal 
artery. Nearly all losses of blood occur in adults, in whom the 
tonsil is more fibrous and thus less likely to retract about the 
divided vessels. It is unnecessary and inadvisable to take off 
the entire gland, for, when cut moderately close to the half- 



Fig. 81.— Author's Tonsillotome. 

arches, it mostly shrinks in a very short time ; if necessary, a 
second tonsillotomy (amygdalotomy) may be practiced. 

In order to use the tonsillotome to the best advantage, an 
assistant should stand back of the patient and press gently over 
the external tonsillar region ; this serves to force the gland 
somewhat from its bed, at the same time that the operator 
passes the fenestrum over the tonsil. If the faucial pillars and 
uvula be free from the line of incision, the blade is thrust home 
and the instrument and tonsil immediately withdrawn from the 
mouth. When the second gland is to be removed, the instru- 
ment is quickly re-inserted and the tonsil excised before the 
child realizes what is being done. As the operation is almost 
painless, it is rarely necessary to use an anaesthetic, but a little 
gentle force is sometimes required. The haemorrhage is usually 
slight, and subsides spontaneously ; it is well, however, to have 



ENLARGED (HYPERTROPHIED) TONSILS. 307 

the patient hold a solution of cold water and gallic or tannic 
acid (1 to 50) in the back of the mouth, as it is not only sooth- 
ing, but aids in controlling the bleeding. In persistent haemor- 
rhage, gallic and tannic acids should be used in combination, 
either dry or in saturated solution, and compression may become 
necessary. Internal remedies should be given early, according 
to indications. Syncope follows loss of a large quantity of 
blood, and, as it usually terminates the bleeding, some encour- 
age it. Should an artery spurt, it must be grasped, if possible, 
and ligated ; but as this can rarely be done, a curved needle 
armed with a strong silk or catgut ligature may be passed into 
the tissue around the bleeding-point and tied. The late Dr. R. 
J. Levis arrested a very troublesome haemorrhage, after failure 
with the ordinary measures, by passing a tenaculum through the 
tissues of the base of the tonsil ; he then gave it a decided 
twist and closed the patient's jaws on the handle of the instru- 
ment, which he held in position by a roller bandage. Haemo- 
static forceps often serve to secure the bleeding-point and arrest 
the haemorrhage ; but the entire tonsillar stump may need 
ligating. Styptics are rarely required ; of these a saturated 
solution of chromic acid is best. The common carotid artery 
has been tied, on account of profuse haemorrhage, and life thereby 
conserved, but in a few cases nothing has saved the patient. 

Mild, more rarely severe, secondary haemorrhage occasion- 
ally occurs two or three days after amygdalotomy. It is usually 
occasioned by the contact of a hard or dry morsel of food ; on 
that account, all food should be soft and bland. 

If the tonsil be very hard, it is unwise to cut it with a sharp 
knife, as the vessels are apt to be dilated and their coats thick- 
ened ; for that reason, a duller blade is preferable, as it crushes 
the vessels as it cuts, although much more force is required to 
push such an edge through the tonsil. In such cases, and 
where the tonsil is too lonir in a vertical direction to enable the 

D 

instrument to encircle it, the snare or Scraseur may answer 
better; the galvano-cautery loop is quicker, but it is difficult 



308 DISEASES OF THE NOSE AND THROAT. 

to prevent contact of the loop with the half-arches. In order to 
overcome this clanger and to facilitate the application of the 
loop and subsequent manipulations, Dr. Knight {Trans. Amer. 
Laryng. Asso'n, 1889) devised a galvano-cautery snare modeled 
after Mackenzie's tonsillotome, but the blade of the latter is 
replaced by a straight, transverse piece of platinum wire. The 
operation is performed as easily and as painlessly as with the 
cutting tonsillotome. In this procedure two points should be 
remembered : (a) if the wire be hot enough to ablate the tonsil 
quickly there is danger of haemorrhage, which will not occur if 
the division be rather slow ; and (b) the destruction of tissue 




Fig. 82.— Knight's Galvaxo-Cauteky Snake. 

will be greater than that actually removed ; due allowance 
should therefore be made. In using Jarvis' snare or the wire- 
loop ecraseur, the same process is carried out as that recom- 
mended in the removal of nasal tumors. It requires from one 
to two hours, depending upon the size and structure of the 
tonsil. The bistoury and forceps are now rarely employed. 

In all of these operations it is important to avoid wounding 
the faucial pillars, lest loss of control of the muscles result or 
annoying haemorrhage follow. The uvula is occasionally burned 
with the galvano-cautery, or amputated in a hasty operation 
with tonsillotome or knife and scissors. This may interfere 
witli the singing voice. 



THERAPEUTICS OF ENLARGED (HTPERTROPHIED) TONSILS. 309 

It would not be right to pass unnoticed the once prevalent 
belief that the removal of the tonsils arrests further sexual 
development and even destroys the patient's virility. Such a 
store of evidence, to the contrary, has been accumulated as to at 
once convince the unbiased that such a result is not only impos- 
sible, but that the removal of these enlargements often gives 
new life to sexual as well as physical development. 

When the tonsils and half-arches are adherent and occasion 
irritation, the points of attachment should be broken down by 
repeated mild probings. Bicarbonate of soda, locally, has often 
decreased irregular glands. 

The remedies best suited to the case are those selected 
according to the general condition, the especial dyscrasia present, 
or the mental state. Pathologically, we are led to calc. carb., 
baryta mur. and carb., graph., iodine, and kali and natr. mur. 
Arnica has reduced the tonsils in several instances, when pre- 
scribed for its constitutional equivalents. 

Therapeutics. 

Ars. iod. — Scirrhous tonsils in phlegmatic persons. 

Baryta carb. will aid in timid, bashful children, who are 
small and "backward for their years": perspiration, especially 
of the feet. I have often been much disappointed in the action 
of this remedy. For similar indications baryta mur. has proved 
more useful. 

Calc. iod. is of decided use when the tonsils are hard, red, 
and nodular. 

Calc. phos. — Especially in strumous subjects, with hyper- 
trophy of various glands, and when the tonsils are flabby and 
pale ; chronic, follicular complications ; difficult deglutition ; and 
impaired hearing. Robert T. Cooper ("Diseases of the Ear") 
says: "I have never found any agent so satisfactory in its action 
upon these glands, when enlarged, as the calcarea jjHiospliorica" 

Fer. phos. — " For chronically enlarged but hypersemic ton- 
sils, preferably with smooth swelling." (Malcolm Leal.) 



310 DISEASES OF THE NOSE AND THROAT. 

Graph. — I have been repeatedly pleased with the action of 
this remedy, when the tonsils were hard and tabulated. 

Ignatia. — Indurated, slightly inflamed tonsils. Clinically, I 
have found no remedy so often useful, especially in nervous 
persons, when the right tonsil is the worse, with associated 
enlargement of the anterior cervical glands. 

Iodine. — "When associated with lateral pharyngeal hyper- 
trophy, the left side the worse. In persons who grow thin even 
with good appetites. 

Merc, proto. — Much tenacious post-nasal mucus. Right 
tonsil worse ; tabulated, with deep interspaces ; pharyngeal 
hypertrophy. 

Sulph. — Harsh, dry, scaly skin ; early morning diarrhoea. 
This remedy — as well as kali raur. and mere. — is especially 
useful if given soon after enlargement begins. 

SUPERNUMERARY FAUCIAL TONSILS. 

These are occasionally encountered, either on one or 
both sides. Unless quite large, they may not attract notice. 
They are usually attached to some portion of the faucial pillars. 
Their treatment, if any be required, is similar to that of 
enlarged tonsils. 

ATROPHY OF THE TONSILS. 

This cannot be looked upon in an unfavorable light, as it 
seems never to give any annoyance. Although it has been fre- 
quently noted post-mortem, it has not received much attention 
during life. 

ENLARGEMENT OF THE LINGUAL TONSIL. 

Etiology. — As the glands at the base of the tongue are so 
similar in structure to the faucial and pharyngeal tonsils, the 
former have been dignified by the name " lingual tonsil." Al- 
though chronic enlargement (hyperplasia) is its chief patho- 
logical deviation, it is not exempt from the acute inflammatory 
changes to which the faucial tonsils are prone. The causes of 
the enlargement are similar to those of the faucial tonsils, 



CALCULI AND CONCRETIONS IN THE TONSILS TONSILLITHS. 311 

although occurring later in life ; they are chronic lymphadenitis, 
overwork and poor nourishment, gout, nasal catarrh, and 
hepatic engorgement. Lennox Browne suggests that this con- 
dition may be symptomatic of mitral disease or cerebral tumors. 
The larynx is often catarrhal. With enlarged lingual tonsil the 
tissues in the glosso-epiglottic region are much thickened and 
varicose veins are present, from rupture of which blood-spitting 
occurs. The epiglottis acts sluggishly. The affection is more 
common in adult females. There is a sensation of a foreign 
body, often resembling globus hystericus; pain frequently 
radiates to other parts ; speech is fatiguing, indistinct ; and 
often there are incessant or spasmodic cough, spasm of the 
oesophagus, difficult or painful deglutition, aphonia, dyspnoea, 
slight haemorrhages, and abscess. 

Diagnosis. — If the tongue be well protruded and the laryn- 
goscope used, the diagnosis is very simple ; but care must be 
exercised not to mistake hypertrophy of the circumvallate pa- 
pillae at the base of the tongue for the condition under considera- 
tion. The space which normally exists between the epiglottis 
and tongue is filled with irregular or even cedematous tissue. 

The prognosis is good. 

Treatment. — General hygienic treatment should be carried 
out as suggested under " Chronic Pharyngitis," and nasal and 
pharyngeal diseases should be cared for. The galvano-cautery 
may be needed, but iodide of glycerin locally and amraon, chlor., 
graph., ham., iodine, mere, iod., and spongia internally, may 
suffice. Perhaps the most durable and satisfactory cautery 
battery is the one devised by Dr. Ledru P. Smock, of Phila- 
delphia. 

CALCULI AND CONCRETIONS IN THE TONSILS TONSILLITHS. 

Etiology. — The secretions of the tonsils are occasionally so 
increased or perverted as to result in the formation, within the 
crypts, of concretions or calculi, sometimes as large as cherries. 
These foreign bodies usually result from the long-retained lacunar 






312 DISEASES OF THE NOSE AND THROAT. 

secretions; although Greening (Archives of Lav., 1882) believes 
them to be parasitic in nature, and advances the proposition " that 
all tonsillar concretions are composed of leptothrix elements." 

Pathology. — Pathologically, these foreign bodies are chiefly 
composed of carbonate and phosphate of lime, with a little iron, 
soda, and potassa. 

Symptoms. — The symptoms are not at all prominent ; the 
patient is often unaware of any annoyance, further than that 
accompanying ordinary tonsillar enlargement, although there 
may occasionally be a sensation of sticking or pricking in the 
throat. The breath is sometimes very offensive. Occasionally, 
calculi and concretions excite ulceration, suppuration, and, pos- 
sibly, spontaneous evacuation. Inspection may detect a foreign 
substance protruding from the tonsil, or palpation locate the 
hardened mass. Its presence is occasionally revealed during 
tonsillotomy. 

Treatment. — The treatment consists in the removal of the 
concretion with curette, scoop, or forceps, after which the sac 
should be treated as suggested under chronic lacunar enlarge- 
ment. 

DISEASES OF THE VALLECULA AND PYRIFORM SINUSES. 

These cavities are rarely the seats of localized diseases, but 
they often participate in the affections of neighboring parts. 
As has been stated, foreign bodies often find lodgment in the 
little valleys, and the same is true of the pear-shaped cavities. 
The irritation arising from the presence of such intruders, as 
well as from various inflammations of the glands, may result in 
ulceration. Finally, dilated (varicosed) vessels and tumors are 
occasionally discovered in these spaces. 

Symptoms. — Ulceration causes a pricking sensation ; pain- 
ful, smarting deglutition ; and, often, cough and hoarseness. 
Tumors may produce similar symptoms, and, usually, interfere 
with deglutition. The sensation of a foreign body is rarely 
wanting. 

Diagnosis. — The diagnosis is usually easy if the laryngo- 



DISEASES OF THE VALLECULA AND PYRIFORM SINUSES. 313 

scope be employed ; but, as mucus usually covers the ulcerated 
surface, the true condition may be overlooked unless the coating 
be first wiped or sprayed away. 

Treatment. — The treatment of ulceration is usually very 
simple, as it generally subsides after removal of the exciting 
cause, if it be a foreign body ; but if it be due to glandular 
degeneration it may require, besides the internal remedy, an 
occasional application of iodol powder, peroxide of hydrogen, 
or a 1-per-cent solution of bichromate of potassium. The treat- 
ment of tumors will be found elsewhere. 

Internally, fluor. ac, kali bi., kali mur., and nitric ac. may 
be demanded, depending upon the symptoms present. 






CHAPTER XXV. 

Catarrh of the Xaso-Pharynx. 



ACUTE NASOPHARYNGEAL CATARRH. 

Etiology. — Although this affection is usually associated with 
inflammation of the nose or pharynx, usually both, there are a 
few cases (according to Sajous especially the scrofulous) in which 
the naso-pharyngeal region is alone involved. The causes are 
similar to those giving rise to pharyngeal and nasal catarrhs. 

Symptoms. — Its symptoms are dryness, burning, fullness 
in the post-nasal region, painful deglutition, and a painful raw- 
ness during deep nasal respiration. The discharge is, as a rule, 
moderately profuse, thin or thick, and exceedingly difficult to 
dislodge, giving rise to tickling cough, fullness, and, in many 
cases, nasal speech and hoarseness. Complaint is often made of 
headache, pain in the ears, and impaired hearing. Inspection 
reveals a bright redness, often roughened condition of the naso- 
pharynx, inflammation and swelling of the pharyngeal tonsil, 
and a thick, even purulent, accumulation in various portions of 
the naso-pharynx. 

Prognosis. — Although the acute affection usually quickly 
subsides, middle-ear catarrh, otorrhcea, or chronic naso-pharyn- 
geal catarrh may result. 

Treatment. — The treatment is similar to that given under 
" Acute Pharyngitis," and need not be especially dwelt upon 
here, further than to say that a spray of an oleaginous sub- 
stance introduced through the nostrils is, as a rule, of decided 
benefit in relieving the annoying symptoms. Some patients 
obtain great relief from the post-nasal application of tannate of 
glycerin, gr. x to 5j. 

There are two or three remedies which deserve special men- 
tion in this connection, namely, caps., ferrum iod., and kali raur. 
(314) 



CHRONIC NASO-PHARYNGEAL CATARRH. 315 



CHRONIC NASO-PHARYNGEAL CATARRH POST-NASAL CATARRH. 

As with the acute affection., chronic naso-pharyngeal catarrh 
is generally associated with chronic nasal or pharyngeal inflamma- 
tions ; but, to judge from the writings of many medical men and 
the complaints of the laity, we must conclude that posterior nasal 
catarrh exists in about eight-tenths of the inhabitants of North 
America. This proportion, however, includes nasal and pharyn- 
geal catarrhs associated with inflammation of the naso-pharynx. 

Etiology. — Its causes are those of acute post-nasal catarrh, 
adenoid vegetations, and chronic rhinitis ; obstructive nasal dis- 
orders, including septal deflections, are of less etiological impor- 
tance. 

Symptoms. — The symptoms are : fullness in the post-nasal 
region; trickling of a mucous, muco-purulent, or bloody dis- 
charge into the oro-pharynx, where it generally appears in 
streaks or lumps of various colors. It may, however, be so 
confined to the naso-pharynx as to come away in lumps or 
crusts, — the result of coughing, or, more especially, hawking, — 
which, if long-continued, not only gives rise to marked irri- 
tation of the throat, but even results in extracting a portion 
of the air from the middle ear, thus producing pressure from 
without and diminution of hearing. The voice is often thick, 
nasal, perhaps hoarse from secondary laryngeal involvement. 
After one or two years the discharge often becomes very thick, 
yellow or green, profuse, and especially annoying soon after 
waking and while eating. At first inodorous, it may, later, 
become offensive, and the hawking necessary to its dislodgment 
so frequent as to render the afflicted one an unenviable com- 
panion ; while the frequent repetition of the act results in con- 
gestion of the faucial region, and, later, thickening or relaxation 
of the uvula and soft palate. (For additional symptoms, see 
"Chronic Rhinitis" and "Chronic Pharyngitis.") 

Prognosis. — The prognosis is very good in so far as life is 
concerned, but the disease is a persistent one; all cases can be 



316 



DISEASES OF THE NOSE AND THROAT. 



relieved, and many cured. It must be borne in mind, however, 
that the ears, pharynx, and larynx may have undergone such 
change as to be beyond relief. It is well known that the general 
system often suffers from the drain, anaemia follows, and the 
patient is rendered more susceptible to other diseases. 

Treatment. — Treatment is both local and internal. Of the 
former, little can be added to that noted under " Chronic Rhi- 
nitis," except that local applications of a similar character (chiefly 
iod. and glycerin, 10 grains to 1 ounce; chloride of zinc, same 
proportion ; and hydr., aqueous tincture), conducted through 
the mouth, and the use of the post-nasal syringe (Fig. 23, page 




Fig. 83.— Leffekt.s' Bulbed Insufflator. 



37), in case the discharge be very thick and difficult to dis- 
lodge, are generally of undoubted benefit. After cleansing 
with a 10-grain aqueous solution of bicarbonate of soda, I know 
of no application so grateful or beneficial as an insufflation of 
powdered gallic acid (1 grain) and gum acacia (2 grains). All 
nasal and pharyngeal disorders liable to induce or perpetuate the 
disease should be remedied. 



Therapeutics. 
Alumina. — "Dryness of the throat, especially on waking 
from sleep; voice is husky, thick; mucus accumulates in pos- 
terior nares, which annoys by dropping into throat (Hydrastis). 
Sensation of tightly adhering phlegm, which cannot be raised 



THERAPEUTICS OF CHRONIC NASO-PHARYNGEAL CATARRH. 317 

by hawking (Iod. mer., Rumex). Talking or singing makes one 
cough (Bry., Phos., Merc.)- Scurfy, sore nostrils, or where there 
are plugs of mucus blocking the Eustachian tubes, with snap- 
ping in ears on chewing or swallowing, and dullness of hearing 
associated with atony of bowels." (G. N. Brigham, " Catarrhal 
Diseases of the Nasal and Respiratory Organs.") 

Argent, nit. — Soreness and rawness of retro-nasal region; 
thick, tenacious, mucous expectoration, resembling boiled starch, 
and easy to dislodge ; rapid accumulation and frequent expul- 
sion. 

Cepa is characterized by the dropping, of a watery char- 
acter, from the naso-pharynx ; laryngeal tickling and cough. 

Hydrast. has profuse, yellow, lumpy, tenacious discharge, 
with frontal headache, constipation, and sensation of goneness 
in the gastric region; smarting, soreness, and rawness in the 
naso-pharynx. 

Kali bi. has, of all remedies, the peculiar stringy, ropy, 
discharge, which often extends down the pharynx, and even 
into the oesophagus. There is always an associated nasal catarrh 
with similar discharges, and, usually, turgid membrane. Fol- 
lowing the use of this remedy, the patient's first relief appears 
in the easier expectoration. 

Kali carb. — Anaemic persons ; morning accumulation of 
mucus, which it is very difficult to dislodge. 

Merc. cor. is one of the best remedies where there is asso- 
ciated tinnitus aurium and impaired hearing, with complaint of 
obstruction, fullness, and tingling in the Eustachian tubes ; 
kali mur. has more the sensation of weight and pressure in the 
middle ears ; with both remedies the naso-pharyngeal tissue is 
hypertrophied. 

Sepia. — Thick, yellow, yellowish-green, offensive lumps or 
crusts are drawn from the posterior nares ; attended by gagging, 
occasionally vomiting. Nasal catarrh, with similar discharge 
and with a pressive, gnawing pain in the bridge of the nose. 

Therid. — "Especially in cases marked by an offensive-smell- 



318 DISEASES OF THE NOSE AND THROAT. 

ing, thick, yellow, yellowish-green discharge ; though I have 
also used it in the earlier stages, while the discharge was still 
watery and light in color. A symptom often observed in the 
chronic as well as in the acute form is ' a heavy feeling or press- 
ure over the bridge of the nose.' This is sometimes expressed 
as ' pressure deep in the upper part of the nose.' I find it neces- 
sary to repeat the theridion every few hours, sometimes for a 
number of weeks, before any positive signs of improvement are 
observed, — one of the earliest being a diminution in the degree 
of offensiveness of odor. I usually employ the 30th potency 
with the best results." (Dr. A. Korndcerfer.) Acting upon the 
doctor's advice, I have relieved the preceding symptoms in a 
number of patients. 

Compare therapeutics of " Chronic Rhinitis," " Chronic 
Pharyngitis," and "Chronic Follicular Pharyngitis." 



PART III. 



The Larynx and its Diseases. 







dsr*c*-&~, 



*!«•*«* £/U."/ fr,7%\ 



CHAPTER XXVI. 

Anatomy and Physiology of the Larynx. 

The larynx is the organ of voice, and as such deserves a 
somewhat extended anatomical consideration. It is situated 
between the base of the tongue above and the first ring of the 
trachea below ; to the former it is attached, in part, by ligaments 
and muscles through the intervention of the hyoid bone, and to 
the latter by the crico-tracheal ligament. 

On each side of it are found the large blood-vessels, nerves, 
and some of the muscles of the neck. The vocal organ is freely 
movable, laterally and vertically, its antero-posterior motion be- 
ing somewhat limited. These various movements occur, as a 
natural process, during respiration, deglutition, vocalization, 
etc., but greater mobility is evident upon manipulation. 

The larynx is composed of a frame-work of cartilages, held 
together by means of ligaments, and moved by the contraction of 
muscles. The interior is lined, or padded, with a continuous coat- 
ing of fibro-elastic tissue, inclosed in a mucous vestment, which 
is continuous with that of the pharynx above and the trachea 
below. The larynx is very superficial anteriorly, covered by little 
more than its cutaneous coating ; posteriorly, it forms the ante- 
rior wall of the laryngo-pharynx. It opens above into the 
pharynx, from which it is sometimes closed by the contraction 
of the sphincter muscles and the descent of the epiglottis ; below, 
it opens into the trachea, from which it is never separated. 

The cartilages which enter into the laryngeal frame- work 
are the epiglottis, thyroid, cricoid, two arytenoid, two Santo- 
rinian, two Wrisbergian, and occasional sesamoid cartilages; 
the thyroid, cricoid, and two arytenoids are true (hyaline) carti- 
lages; the rest are fibro-cartilages. The former are liable to 
ossify in the adult, or as the result of disease, but the fibro- 
cartilages are not so affected. 

21 (321) 



322 



DISEASES OF THE NOSE AND THROAT. 



The epiglottis (Fig. 86) is the thin, leaf-like valve which 
covers the larynx during deglutition, although some observers 
now claim that it remains upright during this act. The stem 
of the leaf is directed downward and is attached to the thy- 
roid cartilage, at its lower receding angle, by means of the 
thyro-epiglottic ligament. It is covered by mucous membrane, 
which is very pale on its posterior (laryngeal) surface, — the seat 
of the openings of numerous glands. Its leaf portion stands 
nearly upright in the majority of adults, though in others it is 
so dependent as to prevent a clear view of the interior of the 





(Anterior view.) (Posterior view.) 

Figs. 85 and 86.— Laryngeal Frame-work. (From photographs.) 

larynx ; in childhood it is usually almost horizontal. Its upper 
(free) margin is very inconstant in shape, and varies from its 
usual double curve to an acute angle. Anteriorly, it is con- 
nected with the tongue by three folds (glosso-epiglottic) of 
mucous membrane inclosing ligamentous bands. The aryteno- 
epiglottidean (ary-epiglottic) folds attach it to the arytenoid 
cartilages, while it is attached to the hyoid bone by the hyo- 
epiglottic ligament. In descending, the tip passes backward, 
sweeping the posterior wall of the pharynx. Besides its aid to 
deglutition, it has an influence upon the quality of the voice, 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 



323 



giving to it much of that character (timbre) which serves to 
distinguish one voice from another ; besides, its flexibility and 
control render vocalizing easier or more difficult (see " Physi- 
ology of the Epiglottis," by the author, Trans. Amer. Inst. 
Homozop., 1890). According to Michelson, this cartilage has a. 
taste-function on its posterior face. For a long time it has been 
known that taste-bulbs were so situated, but it has been but 
recently proved experimentally. 

The thyroid (shield-shaped) cartilage is the largest in the 
laryngeal frame-work. It is composed of two lateral plates, 
which are united, at an acute angle, by an intermediate piece 
of fibro-cartilage, forming the promontory known as Adam's 
apple (pomum Adami). At the anterior upper edge of the 



Hyoid bone 



Eight thy- 
roid plate 

Arytenoid 
cartilage 

Cricoid car 
tilage 

Crico-thy- 
roid joint 





Key to Fig. S6. 



thyroid cartilage is a deep notch (superior thyroid), which can 
be felt externally. To the upper ridge of the cartilage is 
attached the thyro-hyoid ligament, which unites this cartilage 
with the hyoid bone, although Mayo Collier {Ann. Univ. Med. 
Sci., 1889) denies the existence of a true thyro-hyoid mem- 
brane : " All that he finds is a thin fascia lining the inferior 
aspect of the thyro-hyoid muscle, and covering a quantity of 
areolar tissue and fat." The upper edge of the cartilage is 
irregular in outline and terminates, posteriorly, in the superior 
horns (one on each side), which are attached to the hyoid bone 
by means of the lateral thyro-hyoid ligaments. Its lower border 
is also irregular, and has cornua projecting from its posterior 
extremities ; on their lower ends are facets for articulation with 
the postero-lateral surfaces of the cricoid cartilage, by means of 



324 DISEASES OF THE NOSE AND THROAT. 

a capsular ligament and synovial membrane. The motion is 
a tilting one during the contraction and relaxation of the tensor 
(crico-thyroid) muscles. To the lower border of the thyroid is 
attached the crico-thyroid membrane, which unites the thyroid 
and cricoid cartilages. The posterior portions of the thyroid 
plates terminate in vertical, parallel edges, some distance apart, 
thus resembling a shield. Within and attached to this cartilage 
are the vocal ligaments, — the most important vocal structures. 
They pass from the median fibro-cartilage anteriorly, to the 
vocal processes of the arytenoid cartilages posteriorly, and, 
together with the thyro-arytenoid muscles, unite the thyroid and 
arytenoid cartilages. 

The cricoid (ring-shaped) cartilage is often spoken of as 
the basis cartilage, as it is the one which gives chief support to 
the larynx. The band of the ring is placed anteriorly and 
below Adam's apple ; the broad, seal portion posteriorly, form- 
ing a part of the anterior boundary of the laryngo-pharynx. 
On the postero-lateral surfaces of the signet are facets (already 
referred to) for the articulation of the inferior cornua of the 
thyroid ; on the upper posterior surface are two very important 
facets for articulation with the arytenoid cartilages ; the joints 
here formed (crico-arytenoid) are the most perfect in the larynx. 
The movements are very general, and admit a rotary, rocking, 
tilting of the arytenoids upon the cricoid. To the anterior and 
lateral portions of the upper rim of the cartilage is attached the 
crico-thyroid membrane. On the posterior surface is a vertical 
median ridge, upon each side of which is a smooth depression ; 
muscles are attached to both the ridge and cups. From the 
lower border of the cricoid cartilage, which is placed in a hori- 
zontal position, descends the crico-tracheal ligament uniting the 
larynx and trachea. 

The arytenoids, the most movable cartilages in the larynx, 
are two pitcher-shaped, pyramidal bodies, which articulate with 
the cricoid, as already stated. The anterior angle of the base of 
each arytenoid ends in a marked projection — the vocal process. 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 325 

To this is attached the posterior end of the corresponding vocal 
band, into which the process extends. The postero-external 
angle of each arytenoid is known as the muscular process, to 
which important muscles are attached in such a way as to rotate, 
tilt, or even slide the arytenoid. 

The two cartilages of Santorini surmount the arytenoids. 
Their object seems to be, as suggested by Elsberg ("The Throat 
and its Functions"), to act as buffers in preventing the sharp 
contact of the arytenoids during vocalization, in preventing in- 
jury to the arytenoids from impact of the epiglottis or bolus of 
food during deglutition, and for the purpose of more effectually 
closing the larynx during this latter function, at which time the 
cartilages of Santorini incline forward. 

The cartilages of Wrisberg are two wedge-shaped plates, 
frequently found in the ary-epiglottic folds, between the ary- 
tenoids and the epiglottis. They seem to perform the duty of 
giving support to this fold of membrane, but can be of little 
importance, however, as they are frequently wanting. 

The posterior sesamoid cartilages are occasionally found 
attached to the sides of the arytenoids by bands of fibro-elastic 
tissue. The anterior are the size of pins' heads, and act as par- 
tial bonds of union between the thyroid cartilage and the vocal 
bands ; they are sometimes called the anterior vocal processes. 
The anterior ends of the thyroarytenoid muscles pass to these 
cartilages, when present. The inter-arytenoid or Luschka's car- 
tilage is very inconstant, and may appear as a yellow prominence 
in the fold of tissue between the arytenoid cartilages (inter- 
arytenoid fold) and, laryngoscopically, must not be mistaken for 
an abscess. 

The ligaments which unite the various cartilages of the 
larynx are the intrinsic, those which unite the larynx to pther 
parts are the extrinsic, and those which combine these functions 
are designated mixed. The extrinsic ligaments, already men- 
tioned, are the two lateral glosso-epiglottic, the three thyro- 
hyoid, and the crico-tracheal. The epiglottic is the only mixed 



326 DISEASES OF THE NOSE AND THROAT. 

ligament. Its purely extrinsic portions pass from the centre of 
the tongue to the middle of the epiglottis (glosso-epiglottic) and 
from the middle of the epiglottis, anteriorly, to the extremities 
of the hyoid bone, one on each side (hyo-epiglottic) ; its intrinsic 
division unites the lower portion of the epiglottis to the thyroid 
cartilage, immediately below the superior thyroid (thyro- 
epiglottic) notch. 

The most important laryngeal ligaments are the intrinsic ; 
of these the crico-arytenoid and the crico-thyroid have been 
noted. The superior thyro-arytenoid ligaments are composed 
of a few scattered fibres, and go to make up the ligamentous 
structure of the ventricular (false vocal, or pocket) bands. 
They pass backward from the anterior edge of the internal 
surface of each thyroid plate; most of the fibres are attached to 
the anterior surface of the corresponding arytenoid cartilage, 
above the vocal process, the remaining fibres being lost in the 
tissues anterior to the arytenoids. 

The inferior thyro-arytenoid ligaments (vocal bands or 
cords) are the most important vocal structures, without which 
the larynx loses its peculiar characteristic, namely, its vocal 
function ; for, although the ventricular bands are at times called 
into use after destruction of the vocal bands, they do not pro- 
duce a clear, ringing voice. These vocal ligaments are com- 
posed of very strong bands of yellow elastic tissue. They pass 
from the anterior vocal processes, at the receding angle of the 
thyroid cartilage, to the vocal process of the corresponding ary- 
tenoid cartilage posteriorly. Each vocal band is slightly trian- 
gular, or prismatic, with its upper surface almost flat, its lower 
almost straight and placed at an angle of nearly 20 degrees, so 
that its straight surface looks slightly toward the opposite side 
of the trachea ; the external portion, directed toward the surface 
of the neck, is nearly vertical. Anteriorly, the fibres of each 
vocal ligament are collected into a band and attached to the 
re-entrant angle of the thyroid cartilage below the epiglottic 
attachment ; posteriorly, these fibres separate and are attached 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 



327 




c 



to different parts of the arytenoid cartilage, the greater number 
going to the upper surface of (Hfe\ 

the vocal process. 

It has already been stated 
that there is a fibrous cover- 
ing, or padding, over the 
laryngeal cartilages and liga- 
ments, which serves to sepa- 
rate them from the muscles 
and mucous membrane. This 
layer of elastic tissue is dis- 
posed in such a manner as 
to afford protection to some 
parts and greater roundness 
and symmetry to others. 

Proceeding from the car- 
tilages toward the laryngeal 
cavity, the next form of tissue 
to be considered is the mus- 
cular. Although there are 
both intrinsic and extrinsic 
muscles, it is only necessary 
to describe the former, as to 
them belong, chiefly, the duties 
of controlling voice and res- 
piration, in so far as the 
larynx has to do with these 
functions. There are eleven 
of these intrinsic muscles, ten 
of which are in pairs: the 
crico-thyroidei, the crico-ary- 
tenoidei postici, the crico- 
arytenoidei laterali, the thyro- 
ary-epiglottici, and the thyro- 
arytenoidei ; the eleventh is 



>■;■; 



Fig. 87.— Left Side of Larynx, show- 
ing Epiglottis, Left Thyroid Plate 
(Right Half of Thyroid Removed), 
Crico-Thyroid Muscle, Posterior Edge 
of Cricoid Cartilage, and Trachea. 
(From a photograph.) 



328 



DISEASES OF THE NOSE AND THROAT. 



a single muscle, the arytenoideus. The sterno-thyroid, the 
thyro-hyoid, and the inferior constrictor of the pharynx are the 
chief extrinsic muscles, and act upon the entire larynx either to 
elevate or depress it, or to fix it in any desired position. 

The cricothyroid (tensor) muscles (Fig. 87) arise from the 
anterolateral portion of the cricoid cartilage and are inserted into 
the lower and inner borders of the thyroid ; some fibres pass to 

the outer surface. These are the 
only intrinsic laryngeal muscles 
that are placed in front of the 
larynx ; in certain subjects they 
can be felt under the skin during 
their contraction. Their action is 
to tilt the anterior portion of the 
thyroid downward, thus bringing 
the thyroid and cricoid cartilages 
closer together anteriorly ; the tilt- 
ing motion serving to increase the 
distance between the vocal proc- 
esses of the arytenoid cartilages 
and the anterior receding angle of 
the thyroid cartilage, thus stretch- 
ing the vocal bands antero-poste- 
riorly. According to some authori- 
ties, notably Majendie (1813) and 
Hooper (1882), the cricoid is 
looked upon as the movable carti- 
If this be true, the cricoid is drawn 
up to the thyroid. In either case, the result is the same as 
regards the action of the muscles, which are tensors of the 
vocal bands. 

The posterior crico-arytenoids (abductors) are two trian- 
gular muscles which arise from the posterior surface of the 
cricoid cartilage, as stated ; the fibres converge as they pass 
upward and outward, each muscle going to the muscular process 




- 



Fig. 88.— Posterior Crico-Arytexoid 
Muscles. (From a photograph ) 



lage ; the thyroid, the fixed. 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 



329 



of the corresponding arytenoid cartilage. Contraction of these 
muscles rotates the arytenoids in such a way that the muscular 
processes are approximated and the vocal processes and bands 
separated. In rare cases there is an extra muscle, very small 
and often unilateral — the herato-cricoicl. It arises near the origin 
of the posterior cricoarytenoid, and passes upward and out- 
ward to the posterior margin of the inferior thyroid horn. Its 
function is doubtful, but may aid in fixing the inferior cornu, 
opposing, to a slight degree, the fibres of the crico-thyroid 
which pass to the anterior margin of the horn. 

The lateral cricoarytenoid (adductor) muscles pass (Fig. 89) 
from the upper margin and outer face of the sides of the cricoid 



Ary-epiglottie fold 

Cartilage of Santorini 

Pyriform sinus 

Arytenoideus muscle 

Left posterior crico-arytenoid muscle 

Cricoid cartilage 




Epiglottis 
Arytenoid cartilage 
Thyro-ary-epiglottic muscles 
Right posterior crico-arytenoid muscle 



Key to Fig. 88. 



cartilage, upward and backward to the anterior portion of the 
muscular process of the corresponding arytenoid cartilage. Their 
action is directly antagonistic to that of the posterior crico- 
arytenoids ; after the latter muscles open the glottis (the space 
between the vocal bands) to allow the passage of air, the lateral 
muscles are those which chiefly narrow that space preparatory 
to voice production. 

The arytenoideus, or transverse (adductor), is a broad, flat 
muscle (Fig. 88) attached to the posterior surfaces of the aryte- 
noids. It passes transversely from one cartilage to the other ; it 
closes the posterior (cartilaginous) portion of the rima glottidis. 
In this way it assists the lateral crico-arytenoid muscles, for, 
while the latter close the vocal bands from the anterior tips of 



330 



DISEASES OF THE NOSE AND THROAT. 



the vocal processes to their anterior attachments, the former is 
called into action in the approximation of the vocal processes, 
and, consequently, that portion of the vocal bands into which 

these processes enter. The com- 
bined and concerted action of 
these three muscles is necessary 
^ \ ,4|r\ -^L C\ to the proper approximation of 

the bands. Moura, of Paris, 
thinks the arytenoideus assists in 
separating the vocal bands. 

The thy r oar y-epi glottic 
(sphincter or constrictor) muscles 
are the two narrow, flat bands of 
muscular tissue that arise from 
the outer, posterior angles of the 
arytenoid cartilages ; they pass 
from the base of one cartilage to 
the apex of the other, just below 
the cartilage of Santorini. Their 
manner of crossing, on the pos- 
terior surface of the arytenoid 
muscle, is similar to that in which 
braces, or suspenders, cross, thus 
forming an X (see Fig. 88). From 
the apex of the arytenoid carti- 
lage some fibres pass on into the 
ary-epiglottic fold, encircle the 
cartilage of Wrisberg, when pres- 
ent, and on to the sides and free 
edges of the epiglottis. Their 
function is that of a sphincter, by 
which the upper part of the laryn- 
geal aperture is closed. Other fibres go to the laryngeal pouch 
and act as compressors of the sac, emptying the latter when it is 
desired to especially lubricate the laryngeal cavity; some of 




Fig. 89.— Right Lateral Crico- 
arytenoid Muscle. Right Thyroid 
Plate Removed. (From a photograph.) 



Thyroid cartilage 

Lateral cricoarytenoid muscle 




Membranous portion of trachea 

artilaginous ring 
Inter-cartilaginous membrane 



Key to Fig. 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 331 

these fibres continue to the receding angle of the thyroid, and 
aid in drawing the arytenoids and cushion of the epiglottis 
toward each other during deglutition, etc., thus aiding the 
sphincter action. 

The thyroarytenoid (vocal) muscles practically form a 
part of the vocal bands, to the under surface of which they are 
adherent. They arise from the receding angle of the thyroid, 
just below the insertion of the vocal bands, and, passing back- 
ward, are inserted into the vocal processes, bases, and anterior 
surfaces of the arytenoids, some fibres even going to the laryn- 
geal pouch. This is a very complicated muscle, perhaps the 
most intricate in the human frame. It has a number of di- 
visions, all of which have one common origin in the thyroid, but 
their attachments are numerous. The principal divisions are 
the external (lower) and internal (upper). Contraction of the 
former fasciculus draws the arytenoid and thyroid cartilages 
slightly toward each other, thus opposing the action of the 
crico-thyroids, or tensors of the vocal bands ; the external 
thyroarytenoid fasciculi thus acting as relaxors of the vocal 
ligaments ; in addition to which, when antagonized by the crico- 
thyroids, they participate in the closure of the glottis by straight- 
ening the free edges of the vocal bands, giving them firmness 
and support. It is supposed that the action of the internal 
fasciculus of the vocal muscle is to regulate the finer adjustment 
of the free edges of the bands during vocalization. There are 
still other thyroarytenoid fibres which act in the approximation 
of the ventricular (false) bands, and are highly developed in ven- 
triloquists, who make great use of these bands in the production 
of their tones. Some persons can, at will, adduct the ventricular 
bands, independent of voice production. 

Many authorities claim for this much-studied, but too little 
understood, thyro-arytenoid muscle the power of relaxing the 
vocal bands ; others as warmly contend for its tensor powers ; 
but there seems little doubt of the existence of separate fibres 
for the fulfillment of each of these separate functions It is 



332 DISEASES OF THE NOSE AND THROAT. 

probable that its action as a tensor is less than its action as a 
relaxor, since its paralysis results in loss of the voice. 

The thyroepiglottic (depressor of the epiglottis) muscle 
arises from the posterior surface of the thyroid cartilage, below 
the insertion of the stem of the epiglottis ; from this point most 
of its fibres pass upward to the sides of the epiglottis, though 
some pass to the laryngeal sinus. The principal fasciculi 
depress the epiglottis and assist the sphincter muscles ; the 
others aid the compressor of the sac. The middle constrictor 
of the pharynx, in the opinion of Meyer, of Zurich, should be 
considered one of the vocal muscles, and not a muscle of 
deglutition. In the production of certain vocal tones the mid- 
dle fibres of this muscle push forward toward the palate. 

The entire laryngeal cavity is lined with mucous membrane 
continuous with that of the pharynx above and trachea below. 
It is of the ciliated variety, except in the inter-arytenoid space 
and on the upper surface of the vocal bands. From the base 
of the tongue the membrane passes up the anterior surface of 
the epiglottis, over its tip, down on its posterior or laryngeal 
surface to the interior of the larynx, where it incloses the supe- 
rior thyro-arytenoid ligaments, thus forming the ventricular 
bands. From their under surfaces the mucosa passes into 
culs-de-sac, which run up by the sides of the thyroid cartilage, 
sometimes above its upper edge, directly under the visible 
mucous covering. Leaving these sacs, the membrane emerges at 
the upper edges of the vocal bands. The pouches thus formed 
are known as the laryngeal sinuses, or sacs, or as the ventricles 
of Morgagni. Their upper boundaries are the ventricular, their 
lower the vocal, bands. These cavities aid in the production of 
tone, especially by giving support to the vocal bands during 
vocalization. The upper surfaces and free edges of the vocal 
bands are very thinly covered with a continuation of the mucous 
lining, from w*hich it passes to the under surface of the vocal 
ligaments and vocal muscles, thence to the cricoid cartilage, and 
finally to the walls of the trachea. Starting posteriorly at the 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 333 

pharynx, the mucous membrane passes over the thyroid carti- 
lage ; after dipping down almost to its lower border, forming 
the pyriform sinuses, it rises to cover the muscles, cartilages, and 
other tissues which form the basis of the aryteno-epiglottidean 
folds, the Santorinian and arytenoid cartilages, and the inter- 
arytenoid space ; it there becomes continuous with the mucous 
covering of the interior of the larynx, already noted. 

The ary-epiglottic folds extend from the sides of the epi- 
glottis, anteriorly, to the arytenoid and Santorinian cartilages, 
posteriorly. Between the arytenoid cartilages a fold of mem- 
brane incloses the muscles, thus forming the inter-ay tenoid space, 
or commissure, at which place is a marked depression. With 
the high tip of the epiglottis in front, the ary-epiglottic folds at 
the sides, and the arytenoids and inter-arytenoid commissure 
behind, it will be seen that the upper portion of the larynx is 
bounded by sharply-defined walls. (See Figs. 55 and 88.) 

The muscles, ligaments, and cartilages of the larynx are 
destitute of mucous glands, but the mucous membrane is richly 
supplied with them, except at that portion which covers the 
greater part of the upper surface of the vocal bands, where they 
are sparingly distributed. In the posterior portion of each ary- 
epiglottic fold is a collection of racemose glands, from which 
a minute duct extends to the ventricle, the ventricular filter, 
through which the mucus is emptied and from which it is poured, 
when the vocal bands and surrounding structures require lubri- 
cation. In addition to these, there are about sixty small race- 
mose glands situated within the tissues of the ventricle, which, 
when properly stimulated, are capable of pouring out a large 
amount of mucus, but which may act the part of retention cysts 
and give rise to much annoyance and difficulty of diagnosis. A 
third aggregation of glands is found at the cushion of the epi- 
glottis — the glandulo-fatty mass at the lower point of the epiglottis. 
Poirier has recently demonstrated the presence of a lymphatic 
ganglion over the crico-thyroid membrane, which is directly 
connected with the system within the larynx. 



334 DISEASES OF THE NOSE AND THROAT. 

The arterial supply of the larynx is derived from the supe- 
rior thyroid, occasionally from the external carotid through the 
medium of the superior laryngeal, the crico-thyroid, and from a 
branch of the inferior thyroid through the intervention of the 
inferior or posterior laryngeal artery. 

The veins of the larynx have a similar arrangement and 
empty into the internal jugulars. 

The nervous supply of the larynx is derived from the 
superior and inferior laryngeal (recurrent) nerves, branches 
of the pneumogastric. The superior supplies sensation to the 
entire larynx and motion to the crico-thyroid muscles, perhaps 
to the thyro-epiglottic and aryteno-epiglottic as well ; the rest 
of the larynx derives its motor supply from the recurrent nerve. 
The arytenoideus muscle receives its innervation from both re- 
currents, and, according to Mandlestamm, the superior laryn- 
geal and, perhaps, the internal thyro-arytenoid nerves as well. 

Exner's discovery of the existence, in dogs and rabbits, of 
a third or median laryngeal nerve leads to the possibility of such 
a condition in man ; it is, no doubt, of much motor value, and 
may explain that which has heretofore been an unsolved problem, 
namely, that injury of the recurrent nerve seems to affect the 
abductor fibres sooner than those which pass to the adductor 
muscles. It is usually taught that this is due to the superficial 
arrangement of the abductor nerve-filaments ; but Gowers has 
pointed out that the adductor muscles are stronger, owing to 
their right-angled attachment to the base of the arytenoid carti- 
lage, rather than the acute angle of the abductors ; and others 
have demonstrated that stimulation of the cut ends of the re- 
current nerves results in adductor contraction. It is now well 
proved that the divisions of the two superior laryngeal nerves 
cross. Some claim to have demonstrated the existence of laryn- 
geal fibres of the spinal accessory and sympathetic nerves. 
Although the foregoing is the usually accepted theory, the next 
few years will doubtless add much to our knowledge of laryn- 
geal enervation, perhaps revolutionizing the subject. 



ANATOxMY AND PHYSIOLOGY OF THE LARYNX. 335 

In order to aid in explaining some forms of laryngeal 
paralysis, the origin and course of the inferior laryngeal nerves 
will be briefly noted. The right one arises near the apex of the 
lung, in front of the subclavian artery, around which it winds, 
then passes behind the carotid artery, and ascends between the 
trachea and oesophagus. On account of this course, the nerve 
may be compressed by tuberculous infiltrations in the apex of 
the right lung, resulting in paralysis of the corresponding side 
of the larynx; aneurism of the subclavian, innominate, or carotid 
artery at any point near this nerve may have a similar effect, 
and the same may be said of enlarged glands or other tumors 
along its course. The left recurrent arises from the pneumo- 
gastric, in front of the arch of the aorta and on a level with its 
lower border ; after winding around its transverse portion, the 
nerve ascends to supply motion to the left half of the larynx. 
Aneurism of the arch is usually followed by paralysis of the 
muscles of the left side of the larynx. 

In order to complete the anatomical description of the vocal 
organ, it seems only proper to follow the consideration of the 
individual parts by a description of the organ as a whole, and 
this from the stand-point of laryngoscopic investigation. For 
the purpose of study, it has been found convenient to divide the 
laryngeal cavity into three parts, namely : a superior portion, or 
vestibule ; a middle, or supra-glottic portion ; and an inferior, 
or sub-glottic portion. 

The vestibule, very irregular in outline, is bounded in front 
by the epiglottis, on the sides by the ary-epiglottic folds and 
ventricular bands, and posteriorly by the arytenoid cartilages 
and inter-arytenoid space. Its upper boundary is the superior 
boundary of the larynx ; its lower corresponds to an imaginary 
plane drawn directly across the larynx, between the edges of the 
ventricular bands. This division of the larynx is very change- 
able ; during vocalization the sides approach each other slightly, 
particularly the arytenoids, and the inter-arytenoid space is 
nearly obliterated. During deglutition the epiglottis descends 



336 DISEASES OF THE NOSE AND THROAT. 

to cover the laryngeal aperture (denied by some), and contrac- 
tion of the sphincter muscles brings the laryngeal boundary- 
lines in contact, thus obliterating the vestibule. 

The supra-glottic portion is bounded above by the imag- 
inary plane already mentioned ; below, by the vocal bands, 
when approximated, and by an imaginary plane occupying their 
place, when separated. Laterally, the boundary-lines are the 
ventricles of the larynx; anteriorly, the receding angle of the 
thyroid cartilage ; and posteriorly, the inter-arytenoid commis- 
sure and arytenoid cartilages. This portion of the larynx 
changes much less, though more frequently, than does the 
vestibule ; yet closure of the ventricular bands confines it from 
above and adduction of the vocal bands causes the same 
change below. Coaptation of the arytenoid cartilages changes 
the posterior boundary by obliterating the inter-arytenoid fold, 
and adduction of both sets of bands isolates the middle space 
from the other two. 

The -sub-glottic or infra-glottic space extends from the line 
of the vocal bands to the level of the lower border of the cricoid, 
which cartilage confines it laterally. It is practically unalter- 
able, except in its upper portion, the boundary of which changes 
with the action of the vocal ligaments. The only internal 
alteration is from contraction and relaxation of the thyro- 
arytenoid muscles, which swing with the vocal ligaments, and 
either enlarge the cavity or encroach upon it, according to their 
position. These muscles are rather triangular, with the base of 
the triangle directed outward and the apex toward the median 
line, so that the upper part of the sub-glottic space is narrower 
above than below ; in other words, beveled from above down- 
ward and laterally. This formation has a great influence upon 
the expiratory current, and allows the exhaled air to force the 
bands apart when the laryngeal muscles are at rest ; the expi- 
ratory act is, therefore, passive. During inspiration, however, 
the approximated vocal bands present a firm resistance to the 
entrance of air ; hence, it is necessary that the bands be sepa- 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 337 

rated by contraction of the abductors, the function of inspiration 
being active. 

From the preceding it will be seen that the interior of the 
larynx has more or less the shape of an hour-glass. It is usu- 
ally larger in the male than in the female, but it varies in dif- 
ferent individuals of the same sex. Before puberty it is nearly 
the same size in each sex ; but, when this change supervenes, 
the boy's larynx develops very rapidly, the girl's much more 
slowly. 

Vocalization. — Since the vocal bands are the most impor- 
tant laryngeal structures, as regards the production of the voice, 
it will be well to see in what way they serve to bring about the 
phenomenon of vocalization. It can be briefly stated that voice 
is produced by the vibration of the approximated vocal bands. 
In order that the bands be approximated at the proper time and 
to the required degree, it is necessary that the intrinsic laryngeal 
muscles be in good working-order ; that the bands be in a com- 
paratively healthy condition, and not impeded in action by any 
mechanical obstruction. It is, further, necessary that there be a 
fair supply of air in the lungs, in order that the expiratory 
blast, when impinging on the edges of the closely approximated 
bands, be sufficient to cause them to vibrate ; the air thus acts 
as the necessary motor power. Fnally, for the production of 
pure tones, it is necessary that the resonant cavities be in a fair 
condition. 

In producing tone, the action is about as follows : The 
vocal bands are approximated by means of the lateral crico- 
arytenoids, the arytenoideus, and the vocal muscles ; they are 
made tense by contraction of the crico-thyroids, assisted by the 
thyro-arytenoid muscles, the posterior crico-arytenoids acting as 
the proper antagonists and balancers of the muscular action. 
The vocal bands are thus approximated at the time that the 
out-going current of air is forced against them, by the usual 
expiratory forces slightly augmented to meet the extra demand 
needed to set the ligaments in vibration. If, then, the resonant 



338 DISEASES OF THE NOSE AND THROAT. 

cavities (trachea, pharynx, mouth, nose, and accessory sinuses) 
be in their normal condition, the result will be the normal 
human voice. 

In order to produce tones of different pitch, it is necessary 
that the bands vibrate at different rates of speed, and be corre- 
spondingly tensed or relaxed. Thus, the deeper (graver) the 
tone, the slower the rate of vibration, provided the length and 
thickness of the vibrating band be the same. A scientist 
(whose name I have forgotten) makes the following astounding 
statement in connection with voice production : there are " four- 
teen direct muscles which can make 16,000 different sounds, 
and thirty indirect muscles which can make, it is estimated, 
more than 170,000,000 of sounds." 

Ventriloquists vocalize during inspiration. The glottis is 
in the position for producing falsetto tones and, as a rule, the 
larynx is forced down. 

Having thus briefly considered the action of the vocal 
bands during vocalization, it is now to be noted that they are 
rarely quiet, but are in almost constant motion from birth to 
death, whether waking or sleeping. During ordinary inspira- 
tion, as stated, the bands are forcibly separated by the posterior 
crico-arytenoid muscles to allow the entrance of air, the function 
being an active one ; during expiration the bands approach each 
other somewhat, owing to relaxation of these muscles, so that 
expiration is a passive function, the expiratory current serving 
to dilate the glottis as a result of the infra-glottic bevel from 
below upward. It is almost universally taught that, during 
forced inspiration, the glottis is widely opened to admit a large 
quantity of air, relaxation at once following the completion of 
this act ; but to this I have noted a great many exceptions. In 
nearly 30 per cent of the cases in which this function has been 
carefully studied, the effort at deep inspiration is followed by 
only moderate dilatation of the glottis, less than during ordi- 
nary inspiration in the same individual. In order to be certain 
of this, the subject has been requested to alternate the deep 



ANATOMY AND PHYSIOLOGY OF THE TRACHEA. 339 

and ordinary inspirations ; in such cases • the bands were more 
abducted during expiration than during deep inspiration. This 
is due, no doubt, to reflex action ; the effort to inspire deeply is 
transmitted to the lateral crico-arytenoid and the arytenoideus 
muscles, which contract slightly and impede the action of the 
posterior crico-arytenoids. 

During coughing, sneezing, laughing, hawking, etc., the 
bands are brought tightly in contact for an instant, and are then 
suddenly relaxed. During the acts of deglutition, retching, 
vomiting, and holding the breath, the vocal bands are tightly 
coapted. In spasm of the larynx (glottis) this closure continues 
until relaxation of the muscular contraction ensues ; this may 
not be till well-marked carbonization of the blood has resulted, 
or death from asphyxia has closed the struggle. 

The moment a foreign body enters the larynx the vocal 
bands close tightly against it ; a sharp cough usually follows, 
for the purpose of expelling the intruder ; but it often happens 
that a spasm of the adductor muscles occurs, and only relaxes 
after a number of seconds. The spasm may or may not end in 
a cough. When holding the breath for the purpose of making 
an unusual effort, the ventricular and vocal bands are usually 
coapted and the ventricles fully dilated, thus relieving the strain 
which otherwise would fall upon the vocal ligaments alone. 

The ventricular bands often close during the production of, 
the ventriloquist's tones, but never during normal speech or 
song. Dr. T. R. French {Archives of Laryngology, vol. iii) re- 
ports " A Case of Choked Voice, due to Contraction of the Ven- 
tricular Bands," in which inspiratory speech was possible, but 
expiratory vocalization was prevented, after the first tone was 
produced. 

ANATOMY AND PHYSIOLOGY OF THE TRACHEA. 

As the trachea is so evidently a passive organ, and for the 
most part designed for the conduction of air (a pneumatic tube), 
it will not require more than a passing note. It is from four 
to four and one-half inches long, with a transverse diameter of 



340 DISEASES OF THE NOSE AND THROAT. 

about three-quarters of an inch, and an antero-posterior diame- 
ter of a little less. It is not strictly oval in form, but circular in 
all except its posterior portion, where it is decidedly flattened, 
thus resembling a horseshoe. The curved portion is composed 
of from sixteen to twenty incomplete cartilaginous rings (see 
Fig. 87), the posterior portions of which are ligamentous in 
structure, and form the " party-wall " between the trachea and 
oesophagus. Thus, the posterior wall of the trachea is the 
anterior wall of the food-passage, and as the bolus is carried 
down to the stomach the trachea is somewhat compressed 
posteriorly, temporarily diminishing the lumen of the air-pass- 
age ; and since muscular tissue stretches across the posterior 
wall of the trachea, its contraction lessens the calibre of the tube 
and at the same time, no doubt, assists oesophageal deglutition. 
The various tracheal rings are united by fibrous tissue. 

The trachea extends from the lower portion of the cricoid 
cartilage to the upper part of the chest, where it bifurcates into 
the right and left bronchi. The right bronchus is larger than 
the left, and is in a line more nearly corresponding to that of 
the trachea; so that it is not only possible for foreign substances 
to enter it more readily, but it is much easier to obtain a bron- 
choscopic view of the right than of the left. 

The trachea is lined with mucous membrane continuous 
.with that of the larynx ; it is covered with columnar, ciliated 
epithelium, and contains adenoid and glandular tissue. Its 
chief function is to conduct air to and from the lungs, but it is 
also important in that it permits exit to the impurities and dis- 
charges from the lungs and from its own surface, and aids in 
re-inforcina - vocal tones. 



CHAPTER XXVII. 

The Laryngoscope and Laryngoscopy. 

Having considered the anatomy and physiology of the 
larynx and trachea, the desire naturally arises to see these 
organs during life and while performing their various functions. 
This leads to a description of the laryngoscope, the little instru- 
ment that has done so much to revolutionize the study of medi- 
cine. That it has revolutionized the study of the larynx is 
evident, but it has done more : it has gone far to furnish an 
invaluable aid in the diagnosis of many affections quite removed 
from the vocal organs. It is well-known that the condition of 
the lungs is often suggested by aid of the laryngoscope, long 



e.a.yarnall co. phil a. 
Fig. 90.— Laryngoscope. 

before physical exploration gives the least evidence of any pulmo- 
nary defect; and it is a familiar fact that the laryngoscope has 
called attention to the presence of aneurism of the arch of the 
aorta, etc. Thus, it will be seen that the little instrument is by 
no means to be considered unworthy the earnest study of the 
physician in any branch of his profession. That we have not, 
even yet, arrived at the full knowledge of its usefulness is 
evident, for every year adds some new laurel to its former 
achievements; and who can tell what its future will be'? 

More than a century ago attempts were made to examine 
the interior of the larynx during life, but with no decided re- 
sults, and it was not until 1854 that the efforts of Signor 
Manuel Garcia (see page 320) were crowned with success. His 
investigations were so fruitful and so perfect that he gave us 
the instrument in almost its present form ; but to Czermak and 

(341) 



342 DISEASES OF THE NOSE AND THROAT. 

Tiirck belong the honor of applying Garcia's discovery in the 
diagnosis and treatment of laryngeal disorders. 

Formerly, the laryngeal mirror was made in various shapes, 
but at present it is nearly always circular. The mirrors are 
made of silvered glass, and vary in diameter from nine-sixteenths 
of an inch, the smallest, to one inch, the largest size often prac- 
ticable. It is a good rule to use as large a mirror as is conve- 
nient, on account of the larger image obtainable, but size should 
generally be sacrificed to the comfort of the patient. 

In addition to the various apparatus described under nasal 
and pharyngeal examinations, an electric light is made for 




Fig. 91.— Laryngeal Mirrors. (Natural size.) 

examining the larynx; it consists of a combination throat- 
mirror and lamp, so constructed that the light is thrown from 
the lamp on to the mirror, a distance of from one-half to three- 
fourths of an inch. The connection with the battery is made 
through an insulated mirror-handle. In this way the head- 
mirror is obviated, but the heat of the incandescent lamp is often 
uncomfortable, and its presence in the axis of vision is apt to 
obstruct the laryngoscopic view. Fig. 93 illustrates a more 
convenient method of controlling lime-light than does the more 
cumbersome apparatus of Fauvel or Mackenzie. 

Essentially the same position and illumination are employed 
for laryngoscopy as for posterior rhinoscopy; the reflector should 



THE LARYNGOSCOPE AND LARYNGOSCOPY. 



343 



throw the light into the mouth so that the point of greatest 
illumination shall be near the base of the uvula. This is to be 
done by turning the head-mirror in different directions, always 



remembering 



that the angles of reflection and incidence are 



equal. 

When the light has been thrown in the proper direction, 
with the examiner's head in a comfort- 
able position, the laryngeal mirror is taken 
in the hand, as in writing with a pen (see 




Fig. 92.— The S. S. White Dental Mfg. Co.'s Electric Laryngoscope. 

Figs. 92, 94), and the glass surface held directly over the light 
for a few seconds, or until the surface is so warm as to prevent the 
exhaled moisture from condensing upon it. Before introducing 
the mirror into the mouth, the metal back should be placed 
against the palm of the hand, to determine its temperature ; it 
should be warm enough to prevent condensation of the exhaled 



3-W 



DISEASES OF THE NOSE AND THROAT. 



moisture upon its surface, but not sufficiently hot to do violence 
to the delicate mucous membrane of the mouth and throat. 
Some prefer to dip the mirror into hot water and then wipe it 
dry. In order to prolong the examination the surface of the 
mirror may be coated with glycerin ; condensation is thus pre- 
vented, but the image loses in distinctness. In order to obviate 
this blur, Dr. Henry Wright devised an ingenious plan for 
keeping the mirror warm ; to its back is attached a thin platinum, 




Fin. 93.— Beseler's Lime-Light Apparatus. 

A, shade to protect the eye from the rays of light ; B, to connect with oxygen-gas ; C, lime-pencil. 

spiral, insulated wire, which runs along the handle of the mirror 
from a small battery. 

A recent, and often efficient, device for illumination is a 
well-polished glass rod, one end of which is placed against the 
neck over the laryngeal region ; to the other end is attached a 
candle or small incandescent electric glow-lamp. As the light is 
transmitted along the rod, the interior of the larynx is illumi- 
nated, and can then be examined by the aid of the laryngeal 
mirror, warmed and introduced as described. 



THE LARYNGOSCOPE AND LARYNGOSCOPY. 



345 



With the mouth open, the mirror is to be introduced with 
the reflecting surface downward, and in such a way as not to 
touch the tongue ; primarily, because the surface of the glass 




Fig. 94.— Laryngoscopy; in Position. 



would be clouded, thus impairing its reflecting power, and, 
secondarily, as such contact might cause the patient to gag, and 
so seriously interfere with the examination. The back of the 
mirror should be placed gently but firmly against the base of 



346 DISEASES OF THE NOSE AND THROAT. 

the uvula, if the patient will submit to its presence without 
annoyance ; otherwise, it should be held in the mouth in such a 
way as to bring it near the uvula, without, however, touching- 
it. In some cases it is necessary that the patient protrude the 
tongue, when it is to be grasped between the linen-covered 
thumb and index finger of the physician's disengaged hand or 
held by the patient himself; in the latter instance the examiner 
has the great advantage of the free use of both hands. In the 
large majority of cases, however, it will not be found necessary 
to hold the tongue, as the patient will better control its move- 
ments if unhampered by its protrusion ; besides, he will be far 
more comfortable. 

Assuming that the mirror is in its proper position, the 
patient is directed to vocalize and articulate, for the purpose of 
bringing the vocal bands together and elevating the epiglottis; 
the vowels usually selected are a, a, e, as they better serve these 
purposes. At the same time that the epiglottis is raised the 
vocal bands approximate, and a good view of the larynx is 
usually the result. If it be desired to see below the glottis, the 
patient should be requested to breathe deeply, thus separating 
the vocal ligaments and permitting a view of the deeper parts, 
often to the bifurcation of the trachea, in some cases even into 
the right bronchus. 

It must not be supposed that laryngoscopic examination is 
unattended by difficulties, for they are sometimes numerous 
and not easily overcome ; but a little care and experience will 
usually suffice to conquer them all. If the tongue obstruct 
the view, this hindrance may be overcome by pulling that organ 
carefully, but well, forward with the aid of a napkin. In order 
to protect the fraenum, the index finger should be placed against 
the upper edge of the lower incisor teeth in such a manner as 
to slightly elevate the tongue. If holding the tongue fail, its 
base may, at the same time, be held down by a tongue-depressor 
or the back of a second laryngeal mirror ; usually, however, it 
is better not to have the tongue simultaneously protruded and 






THE LARYNGOSCOPE AND LARYNGOSCOPY. 347 

depressed. Should the tonsils be too large to admit the easy 
introduction of the usual mirror, a small one may be inserted ; 
and where the irritability of the fauces interferes with the posi- 
tion of the laryngoscope, this can usually be overcome by placing 
the mirror well in the roof of the mouth, first assuring the 
patient that he will not be touched if he hold the head well back 
and still. If this fail, the patient can usually soon overcome 
the sensitiveness by frequently introducing his finger or a piece 
of polished hard-wood into the back of his mouth. If, how- 
ever, it be advisable or necessary to examine a sensitive throat 
at once, a 4-per-cent solution of cocaine may be sprayed upon 
the fauces and pharynx ; in its absence, much can be accom- 
plished if the patient hold pieces of ice well back in his mouth. 
With some, the mind has such an influence that they begin 
retching or even vomiting before the mirror has entered the 
mouth ; such persons should close their eyes before the intro- 
duction of the mirror. 

Should the epiglottis be so dependent as to obstruct the 
view, the examiner should stand, the patient's head thrown well 
back, and e sounded. In rare instances this will fail, when it 
will be advisable to elevate the tip of the epiglottis with a soft 
probe ; this causes but little irritation, which is quickly allayed 
by cocaine. C. M. Blackford, of Lynchburg, accomplishes the 
same object by pressing upon the glosso-epiglottic ligament with 
a bent probe. When this complication is encountered in chil- 
dren, it may usually be overcome by causing the patient to gag 
by an extra pressure of the mirror against the pharynx. Chil- 
dren, unless obstinate or frightened, are usually very tractable. 
Where stubborn resistance is encountered, the gag and strait- 
jacket may be required. In my experience, failure is the ex- 
ception after five years of age, and success is frequent at two. 
It is rarely necessary to resort to general anaesthesia. 

In examining a little child, he should be seated on the lap 
of the parent or nurse, who is to place her hand on the child's 
forehead and gently hold his head against her chest ; but after 



348 DISEASES OF THE NOSE AND THROAT. 

the sixth or seventh year the patient may be seated on a high 
chair or stood on the floor by the side of the light. 

Inspection of the posterior wall of the larynx is a very 
difficult feat, as a rule, but Gustav Killian, in his monograph, 
" Die Untersuchung der hinteren Larynxwand," suggests two 
methods by which this may be accomplished: (1) The head is 
" thrown backward, and a mirror (holding the epiglottis out of 
the way) " reflects " the posterior surface of the larynx on a 
second mirror held against the velum palati " ; (2) the patient 
stands with his face downward, and the physician kneels while 
he reflects the light and obtains the image of the posterior wall 
of the larynx upon a mirror held against the mouth and soft 
palate. 

Tumors, abscesses, haemorrhages, or an ankylosed jaw may 
defeat a laryngoscopic examination. Before examining the 
larynx of a child or a very nervous adult, it is advisable to take 
the reflector in one's hand, perhaps polish its surface, and let 
the patient see himself in it ; the same is true of the laryngeal 
mirror. 

THE LARYNGEAL IMAGE. 

It is important to pause a moment before considering this 
in detail. It will be remembered that the only method of 
observation is by reflection and that there will be some fore- 
shortening of the image, which is, however, of little moment 
compared with the transposition which occurs, and which can be 
best explained by a diagram (Fig. 95). The V will represent the 
abducted vocal bands ; its apex the anterior commissure ; there- 
fore, nearer to the examiner than the free ends, which will 
indicate the arytenoid cartilages. A laryngeal mirror placed 
above this will picture the V reversed upon its surface. It will 
thus be seen that the image of the larynx is transposed antero- 
posteriorly, but not laterally, as shown by the heavy side of the 
V. The epiglottis and anterior commissure are thus represented 
as situated posteriorly to the arytenoids ; but the sides of the 
larynx retain their proper positions, — an important point to 
remember when treating the larynx mechanically. 






THE LARYNGEAL IMAGE. 349 

If the beginner see beyond the base of the tongue, the first 
object which usually greets his eye is the epiglottis. This ap- 
pears in the mirror as a vari-formed lip, usually presenting the 
curves of the line of beauty, but it may be indented, notched, 
irregular, horseshoe-shaped, etc. (see page 350). It usually 
changes position during the production of tones, on forced res- , 
piration, during retching, etc. ; in color it is much like the 
gums. Its curled lip and posterior surface are often marked by 
capillary vessels. While the entire laryngeal surface of the 
epiglottis may come into view during vocalization, it is some- 
times possible to see the anterior face and tip only. Occasion- 
ally in children, rarely in adults, the lingual surface of the epi- 
glottis can be seen by direct vision 
when the tongue is forcibly depressed. 

Extending from the centre of the 
anterior surface of the epiglottis to 
the tongue is the central glosso-epi- 
glottic fold, which appears as a verti- 
cal line, presenting much, the same 
character as the frsenum of the tongue. 
On each side of this fold are noticed 
depressions, the valleculas (little val- 
leys), in which food and foreign sub- 
stances sometimes lodge. Extending from each side of the 
epiglottis are the aryteno-epiglottidean folds. They terminate, 
posteriorily, in the cartilages of Santorini (supra-arytenoids), 
which appear as two knobs, below which is seen the covering 
of the arytenoid cartilages ; between these is the inter-arytenoid 
or posterior commissure, on a lower level than the cartilages 
of Santorini. In some cases the only portions of the larynx 
visible beyond the epiglottis are the two prominences of the 
arytenoid cartilages, — the Santorinian knobs ; in which case 
the mobility of the vocal bands can be assumed by the ap- 
proximation and separation of these indices. By their ap- 
pearance alone it is sometimes possible to fairly well diagnose 




Fig. 95.— Reflection of V- 
Shaped Figure ok a Laryngeal 
Mirror. 








/\ i 




l. A 




THE LARYNGEAL IMAGE. 



351 



phthisical and other diseases situated within the laryngeal 
cavity. In the ary-epiglottic folds are often seen roundish 
prominences, — the cartilages of Wrisberg. Just without and at 
the sides of this prominent entrance-circle are seen the deep 
cavities known as the pyriform sinuses (hyoid fossae), while 
within this crater-like mouth is the interior of the larynx (the 




Fig. 102.— Normal Larynx during Respiration. 

vestibule), at the sides of which are the ventricular bands. At 
the first glance they are not different in appearance from the 
sides of the larynx ; for this reason the novice is very apt not to 
recognize them ; but it will be noticed that their edges, directed 
toward the median line, are quite sharp, overhang, and nearly 



Cushion of epiglottis 

Right ventricular band 

Right vocal band 

Ary-epiglottic fold 

Left bronchus 

Right bronchus 

Cartilage of Santorini 

Inter-arytenoid fold 




Epiglottis 
Vallecula 
Glottic space 
Ventricle 
Pyriform sinus 
Tracheal ring 
Cartilage of Wrisberg 
Arytenoid cartilage 
Posterior laryngeal wall 



Key to Fig. 102. 



hide from view the openings to the ventricles of Morgagni. 
These ventricles appear as shadows or little caverns in most 
instances, but when the mirror is held diagonally they often 
look quite large ; below these are seen the vocal bands proper, 
which should be pearly white and glistening. They extend 
from below the cushion of the epiglottis, where they unite, at a 



352 DISEASES OF THE NOSE AND THROAT. 

very acute angle, to the arytenoids, at which point they are 
either close together (phonatory position) or far apart (respira- 
tory position), depending upon the location of the arytenoids 
and their vocal processes. It will thus be seen that the respira- 
tory glottis is often triangular, with its apex anterior and its 
rounded base (the inter-arytenoid space) posterior. The glottis 
is divided into an anterior (ligamentous) and posterior (carti- 
laginous) portion ; the anterior is formed by the ligamentous 
portion of the vocal bands, while the posterior is formed by the 
vocal processes of the arytenoids. At the junction of these 
portions is often seen a yellow, white, or pink spot which indi- 
cates the tip of the vocal process. In health the ligamentous 




Fig. 103.— Normal Larynx dtjking Phonation. 

portion of the bands is always pearly white, but the cartilaginous 
part is often a dull, almost chalky, white. 

Near the lower portion of the epiglottis, just above the 
anterior extremities of the vocal bands, is seen a roundish 
prominence, brighter red than the surrounding mucous lining, 
— the cushion of the epiglottis. 

When the white vocal ligaments are approximated, only a 
shadow-line is seen between them ; but, when separated, it is 
usual to see below the cricoid cartilage, and, on a still lower 
level, the crico-tracheal membrane and some rings of the 
trachea, with the intervening membranous tissue. In some 
cases the bifurcation of the trachea and two or three rings of 
the right bronchus are easily visible ; the left bronchus is too 
much to the side and too small to be illuminated, although one 



THE LARYNGEAL IMAGE. 



353 



can sometimes see a short distance into it. The tracheal rings 
are grayish, the intervening spaces presenting a color not unlike 
that of the ventricular bands. 

In making a thorough examination of the larynx and 
trachea, much care should be given to the position of the 
patient's head and to the angle at which the mirror is held ; the 




Fig. 104.— Auto-Laryngoscope. 

latter can only be acquired by a fair amount of practice, while 
the former is to be regulated by the dependence of the epiglottis 
and the desire to see the deeper parts. In examining the 
trachea it is often necessary to have the patient sit very erect, 
the head not thrown back, but rather inclined forward, the 
examiner's eye below the patient's mouth, and the light thrown 
slightly from below upward into the laryngeal mirror. The 



354 DISEASES OF THE NOSE AND THROAT. 

patient should breathe deeply in order to separate the vocal 
bands as much as possible. 

In the absence of a laryngoscopic mirror, Voltolini advised 
the following manipulation for examining the epiglottis and, in 
many cases, the arytenoid region : The tongue is protruded and 
held between the patient's thumb and finger; the physician, 
with one hand, elevates the larynx from without, while with 
the other he forces the tongue downward and forward. 

Laryngeal photography has been quite successfully accom- 
plished, especially by French, of Brooklyn, and others. As yet 
the general application of this art is not practical, as consider- 
able special preparation is necessary and a large amount of 
practice required not only on the part of the operator, but fre- 
quently of the patient as well. It may, therefore, at present, be 
looked upon as a scientific procedure of limited utility, although 
its future must be a brilliant one. 

AUTO-LARYNGOSCOPT. 

In order that one may examine one's own larynx, it is 
necessary to make some modification in the preceding apparatus 
and methods of application. For this purpose all that is necessary 
is a laryngeal mirror, as in altero-laryngoscopy,a good light placed 
in front for direct illumination, and a plane-mirror held between 
the mouth and the light, but a little above the latter. This can 
be modified so that the light is at the side and thrown into the 
mouth by reflection from the hand-mirror, or the plane-mirror 
may surmount a globe of water, which serves to concentrate 
the light of a candle, lamp, or gas-flame, situated beyond it, as 
suggested by Foulis. While it is often possible to make satis- 
factory auto-laryngoscopic examinations, the beginner must be 
prepared for repeated failures. 



CHAPTER XXVIII. 

Neuroses of the Larynx. 

Neuroses of the larynx are divided into those of sensation 
and those of motion. Among the former it is nsual to consider 
anaesthesia, hypersesthesia, pallesthesia, and neuralgia. Neu- 
roses of motion are divided into defective or absent muscular 
action, functional paralysis, and spasm. 

The normal laryngeal sensibility varies greatly in diiferent 
persons, and even in the same individual at different times ; but 
when this deviation passes beyond certain limits, it is looked 
upon as abnormal. It is not always easy to draw this line, but 
one must be guided by experience and by comparison of a large 
number of cases. 

Anaesthesia (lack of sensation) is scarcely to be considered 
a distinct and independent affection, as it depends upon a general 
physical state, more than upon a direct nervous deviation from 
the normal; hence it is not thought best to discuss it here, 
further than to enumerate the maladies which may give rise to 
it. The diseases which cause, accompany, or complicate it are : 
diphtheria, syphilis, typhus, variola, erysipelas, long-standing 
chronic catarrhs, epilepsy, chorea, hysteria, insanity, bulbar 
paralysis, apoplexy, tumors at the base of the skull, locomotor 
ataxia, progressive muscular atrophy, and railroad spine. In 
many diseases, anaesthesia occurs a few hours preceding death. 

Hypersesthesia (increased sensation) is reflex, as a rule. 
Among its frequent causes are gastric derangements, especially 
in those who indulge to excess in alcoholics and condiments. 
Hysteria, improper use of the voice, rheumatism, and gout are 
doubtful etiological factors. Its chief manifestation is a loud, 
barking cough, the so-called " nervous cough," which is not an 
unusual accompaniment to hysteria, follicular pharyngitis and 
laryngitis, and laryngeal phthisis. 

(355) 



356 DISEASES OF THE NOSE AND THROAT. 

Paresthesia (perverted sensation) often exists without 
appreciable cause (hysterical), but it frequently has a discover- 
able origin, such as a glandular enlargement or a varicose con- 
dition at the base of the tongue and lateral pharyngeal walls. 
A perverted sensation of heat, cold, swelling, hair, etc., occa- 
sionally precedes laryngeal phthisis. Should a varicose condition 
be present, the failure of aesch., bry., hamam., ignatia, and lach. 
to accomplish a cure should at once lead to the use of iodide 
of glycerin or the galvano-cautery. The almost white-hot point 
of the latter should be applied, if possible, to the base of the 
afferent vessel ; the application to be sufficient to interrupt the 
circulation in but one vessel at a sitting. The cure is often 
difficult unless the cause be ascertained. 

Neuralgia of the larynx is exceedingly rare, and is gener- 
ally found in the anaemic, malarial, rheumatic, or gouty; or 
associated with some more general neuralgia. This condition 
must not be confused with beginning laryngeal changes, more 
especially with senile perichondritis ; in the latter the laryngo- 
scope will aid in revealing the condition, as no laryngeal change 
is visible in neuralgia. 

The prognosis is usually good. The treatment is chiefly 
symptomatic, though manipulation, electricity, and a change of 
air are often indicated. 

Paralyses are due (1) to a central cause (rare); (2) to 
disease at the root of the nerve (rare) ; (3) to a change some- 
where in the course of the affected nerve (frequent) ; or (*±) to a 
local affection of a few nerve-filaments or of the muscles 
(frequent). 

In the first division, in which there is paralysis of muscles 
in other parts of the body, search should be made for haemor- 
rhage, tumor, encephalitis, disseminated sclerosis, syphilitic 
deposit in the pons or medulla oblongata, tabes dorsalis, or lead 
poisoning ; in the second, for a change in the medulla or its 
vicinity; in the third, for injury, nerve-pressure by a tumor, 
enlarged gland, or aneurism ; and in the fourth, for nerve trau- 



NEUROSES OF THE LARYNX. 357 

matism, atrophy, degeneration, or a syphilitic or tuberculous 
deposit. 

If purely local in origin, special filaments may become 
affected by accident or disease ; or the muscular fibres them- 
selves may be impaired by pressure of foreign bodies, injury, 
ulceration, inflammation, infiltration, fatty degeneration, atro- 
phy, or pressure from surrounding pathological changes. If 
the nerve be long inactive the muscle will be impaired, and 
fatty degeneration or atrophy may follow. 

When the lesion is central, the paralysis is either unilateral 
or bilateral, and affects either the inferior or superior laryngeal 
nerve, or both, and other muscles of the body will usually be 
found paralyzed as well. 

If the superior laryngeal nerves be affected, laryngeal sen- 
sation will be destroyed and the crico-thyroid and thyro-ary- 
epiglottic muscles will be paralyzed, the voice very defective, 
and the epiglottis upright. The latter, in conjunction with 
anaesthesia of the laryngeal mucous membrane, will permit the 
passage of food into the larynx or deeper parts. In paralysis 
of one superior laryngeal nerve, the epiglottis will be anaesthetic 
on one side and irregularly active, the result of paralysis of one 
thyro-aryteno-epiglottic muscle ; tension of the vocal band will, 
also, be defective, on account of paralysis of the corresponding 
crico-thyroid muscle. If the inferior laryngeal be the nerves 
involved, the remaining laryngeal muscles will be palsied and 
tracheal sensation abolished. 

Paralysis of all the muscles supplied by one recurrent often 
gives very meagre subjective symptoms. The voice may be only 
weak and uncertain ; sometimes, however, it is lost. The laryn- 
goscopy appearances are characteristic ; the band on the affected 
side remains immobile in the mid, or cadaveric, position, as 
found after death. During inspiration the unaffected band is 
widely abducted; and, although, on attempted phonation, it may 
only reach the median line, as a rule, it passes beyond it in the 
effort to assist the vocal function, by assuming a share of the 



358 



DISEASES OF THE NOSE AND THROAT. 



work of its disabled companion. Although the paralyzed liga- 
ment be in the cadaveric position, far from that of phonation, 
it is possible for the voice to be quite good, owing to the passage 
of its fellow beyond the middle line. If the arytenoid and San- 




Fig. 105.— Freshly-Dissected Larynx, showing Cadaveric Position of Both 
(From a photograph.) 

torinian cartilages of the normal side be carefully watched, they 
will be seen to occupy the usually normal position of the inter- 
arytenoid space, but often in front of their companions. 

Differentiation between general unilateral recurrent paraly- 



Glosso-epiglottic ligament 

Epiglottis 

Left ventricle 

Left vocal band 

Arytenoid cartilage 

Inter-arytenoid fold 




Tongue 

Vallecula 

Ary-epiglottic fold 

Right ventricular band 

Glottic space 

Pyriform sinus 

Greater horn of thyroid cartilage 



Key to Fig. 105. 



sis and paralysis of one lateral crico-arytenoid is not always 
easy ; but, in the latter affection, the palsied band lies well to 
one side of the larynx, far from the mid-position, and the voice 
is much more affected than with unilateral recurrent paralysis. 




PARALYSIS OF INDIVIDUAL MUSCLES. 359 

If both bands be paralyzed as the result of involvement of 
both recurrents, with total paralysis of all the muscles supplied, 
the voice will be lost and both bands in the cadaveric position. 
(See Fig. 105.) 

A word of caution is here called for in the way of exami- 
nation. If the head of the patient be turned to one side, it is 
easy to mistake a right-sided paralysis for one existing on the 
left, and vice versa, as the twisting of the head may give the 
impression that the paralyzed band is the one which is in the 
position for phonation. If, however, the 
bands be watched while the head is upright, 
it is easy to determine which is the active 
one. Again, the mirror should be held in a 
position to receive the image of the larynx 
in a vertical manner; a disregard of this 
precaution may give rise to the same error. 

It is important, in all forms of paral- FlG . 106 ._ LbP t RECxrE . 
ysis, to exclude the possibility of direct ?#g T attempted' pho- 
mechanical impediment to the motion of 
the bands ; those most frequently encountered are infiltration, 
tumors, foreign bodies, perichondritis, oedema, and ankylosis of 
the crico-arytenoid joints. 

PARALYSIS OF INDIVIDUAL MUSCLES. 

Loss of power in one crico-thyroid muscle gives rise to 
lack of tension of the vocal band on the side paralyzed, and a 
weak, unsteady, easily-fatigued voice. According to Mackenzie, 
the laryngeal appearances are characteristic, the band is wavy 
and very relaxed during attempted phonation ; at the same time 
the normal band comes promptly to its median position. To 
this " wavy " condition I (with some others) am unable to sub- 
scribe, never having seen it occur ; the band being simply 
relaxed even during strong efforts at vocalization. Should both 
muscles be involved, the picture is double and the voice nearly 
abolished. 



360 DISEASES OF THE NOSE AND THROAT. 

If there be defective action on the part of one thyro- 
arytenoid (vocal) muscle (thought improbable by some writers), 
it will be manifested by a weak and uncertain tone, which grows 
worse from use. The band is thinned and arched, consequently 
it does not come in contact with its fellow. Paralysis of both 
these muscles is the usual condition and leads to marked hoarse- 
ness, especially during production of the middle and higher 
tones. Lennox Browne says : " Paralysis of the internal fibres 
only leads to loss of falsetto notes." Gottstein has called atten- 
tion to the marked approximation of the ventricular bands 
during paralysis of the thyro-arytenoid, and cautions the ex- 
aminer against the error of mistaking the condition for one of 
ventricular thickening. 

Thyro-arytenoid paralysis is generally 
•=/ associated with catarrh of the vocal bands, 
generally acute or subacute, but some- 
times chronic. It is usually the result 
,keal of inflammatory infiltration, and generally 
ysTmr™ ^^: subsides with the catarrh upon which it 
depends. Severe and improper use of the 
voice may occasion this form of paralysis, either by straining or 
rupturing some of the muscular fibres. It is important to dis- 
tinguish this condition from that which is found in the normal 
larynx, during the production of the lower as well as the very 
high tones. By neglect of this distinction, some observers have 
seemingly discovered paralysis when the condition was normal. 
If the person sound a note in the middle (upper thick) register, 
it will be seen that the elliptical opening disappears if due to 
the mechanism, but if the result of a pathological defect it will 
remain unchanged. 

The prognosis is usually good. 

The treatment is to be symptomatic, directed toward the 
removal of the cause, and supplemented by the use of the faradic 
current, as later noted. As a rule, it is well to enjoin tem- 
porary rest for the voice. 




PARALYSIS OF INDIVIDUAL MUSCLES. 361 

Paralysis of one lateral crico-arytenoid muscle is unusual; 
as already stated, there is generally aphonia ; the affected band 
is widely abducted and almost or quite immobile, depending 
upon the extent of the paralysis. When both muscles are 
involved (the usual form) the picture is still more characteristic ; 
the bands are abducted to the fullest degree, the voice is abol- 
ished, and the effort to speak attended by great fatigue of the 
abdominal muscles. The air rushes in through the open glottis 
with little hindrance and without making any sound (von 
Ziemssen's " phonetic waste of breath "), causing a rapid 
emptying of the air-cells at the expense of the diaphragm and 
abdominal muscles. 

It has for its general causes diphtheria, lead or arsenical 
poisoning, anaemia, hysteria (?), uterine derangements (especially 
amenorrhcea), severe illnesses, syphilis, etc. ; and strain, cold, or 
trauma as local influences. 

The prognosis is good. 

Treatment directed toward the cause will usually prove 
curative. 

Posterior crico-arytenoid paralysis of one side may not be 
attended by any symptoms calling attention to the condition if 
the person affected be very sedentary in his habits ; but if he 
use any violent exercise, or go up-stairs quickly, he may suffer 
from slight dyspnoea. When the larynx is examined, the 
affected band will be seen near the median line and immovable. 
It is possible that the arytenoid cartilage may move a little 
toward the opposite one when a phonatory effort is made, but 
it is so slight that it causes no appreciable movement of the 
band, which is nearly in its normal vocalizing position. It is 
not surprising, therefore, that the voice is often natural, and 
that the condition is frequently overlooked. 

When both bands are paralyzed the condition is very 
different ; it is not only serious, but immediately threatens life. 
The voice may be normal ; but if the paralysis be pronounced, 
the dyspnoea will be intense and alarming. Any exertion or 



362 DISEASES OF THE NOSE AND THROAT. 

excitement greatly aggravates the dyspnoea and renders the con- 
dition distressing; in the extreme. At night the breathing is 
often so noisy as to be heard some distance, owing to the accu- 
mulation of mucus and to spasm, as a result of which the patient 
may suddenly expire. Tracheotomy is the one measure called 
for in these cases, and, although in some instances the symp- 
toms are no£ so aggravated as to be at once dangerous to life, 
yet, where there exists a veritable paralysis of the posterior 
crico-arytenoid muscles, there is no real safety to the patient 
unless he wear a tracheotomy-tube, as a mild condition may at 
any time suddenly become very serious. Repeated forced chest 
expansion with almost closed glottis sucks the blood into the 
pulmonary vessels and, as it does not return freely to the heart, 
gives rise to severe pulmonary congestion, 
still further complicating the case. 

Etiology. — The chief causes of abductor 

paralysis reside in impairment of the nerve, 

due to pressure, stretching, or other injury ; 

fig. ios.-bilaterai. or impairment of muscular contraction, due 

Posterior Crico-Ary- . . 

tenoid paralysis, dur- to direct mmry to the muscles through lodg- 

ing Inspiration. . 

ment of a foreign substance at the pharyngo- 
cesophageal junction, directly over them. One of the chief causes 
of nerve-pressure is aneurism ; therefore, remembering that the 
left recurrent partially encircles the arch of the aorta, it is not 
strange that this is the one most frequently paralyzed ; but 
aneurism of the subclavian or innominate artery may affect the 
right nerve. Other pressure factors are benign or malignant 
tumors, enlarged bronchial or other glands, tuberculous deposits 
in the apex of the right lung, syphilitic cicatricial stricture of 
the oesophagus, and pericardial effusions. Abductor paralysis 
sometimes follows severe illness, especially typhoid and typhus 
fevers ; in a small percentage of cases the etiology is obscure. 

It differs from spasm in the slowness of its onset and in its 
persistent and unchangeable character. It is to be distinguished 
from ankylosis of the crico-arytenoid joints by the absence of 




PARALYSIS OF INDIVIDUAL MUSCLES. 363 

the history of previous ulceration or perichondritis ; but rheu- 
matic and gouty arthrites are possible. 

Prognosis. — The prognosis is grave except in cases due to 
syphilis. After tracheotomy the patient may live for years in 
comparative comfort so long as he wears the tube ; a few cases 
are cured. (See author's report of such a result eight months 
after tracheotomy, Halmemannian Monthly, January, 1884.) 
Fortunately, bilateral paralysis of the posterior crico-arytenoids 
is rare ; the unilateral form is more frequent. 

Paralysis of the transverse (arytenoideus) muscle must 
be bilateral. The voice is somewhat affected, but not lost, 
and there is phonetic waste of breath. 

During vocalization, with arytenoideus 
paralysis, the laryngoscope shows the bands 
adducted except at their posterior extremi- 
ties, where there is a triangular separation, 
owing to failure of the arytenoideus to coapt 

,t_ -. P , -i , .j ,-i FIG. 109. — ARYTENOID 

the vocal processes ol the arytenoid cartilages paralysis, during vo- 

CALIZATION. 

or to tilt the cartilages toward each other. 

The cause is chiefly catarrhal, the result usually good, and the 

treatment medicinal. 

It is not only possible to have the various muscles sepa- 
rately involved, as already described, but to have a combined 
paralysis of two or more of them, in which event the laryngo- 
scope presents a combined picture of paralysis. 

Prognosis. — The result of laryngeal paralysis depends upon 
the cause, the duration of the affection, the condition of the 
patient, and the treatment employed. If of central origin, it is 
not likely that the patient will recover ; he may do so if the 
alteration giving rise to the palsy be removed before any serious 
structural lesion has taken place; more especially is this true 
when syphilis is the cause. When the condition causing the 
paralysis is situated in the course of the nerve itself, the same 
prognosis will apply. If the paralysis be of an individual 




364 DISEASES OF THE NOSE AND THROAT. 

muscle, it can often be cured if no fatty changes have occurred ; 
but after such degeneration it is rare for the defect to be 
remedied, and atrophy of the muscle precludes the possibility 
of a restoration of function. Functional paralysis (to be later 
considered) must not be confounded with the organic disease. 

Treatment. — Treatment is usually to be considered from 
the stand-point of the cause ; any other method is apt to meet 
with signal failure. If the original impulse be syphilitic, the 
systemic disorder should be dealt with as suggested under 
"Syphilis," in Parts I, II, and III. Intercurrent remedies are 
not to be neglected in any event ; chief of these are calc. c, nitr. 
ac, mix vom., and sulph. It is necessary to caution against too 
long continued use of the lower preparations, as it may re- 
sult in an aggravation of the condition. Should the cause be 
the pressure of a tumor on a nerve, either at its origin or in its 
course to the larynx, the tumor needs the surgeon's prompt 
attention in order to relieve the pressure before lasting harm 
results, provided no remedy be found to speedily cure. In the 
meantime, it is usually advisable to stimulate the muscles by the 
electrical current, as this acts in delaying fatty degeneration and 
atrophy. It is necessary, in this connection, to speak of one 
danger which may follow the use of electricity within the 
larynx: If there be paralysis of the abductors, it is quite pos- 
sible to overstimulate the action of their antagonists, and, by 
suddenly and completely closing the glottis, induce fatal dyspnoea. 
It must be remembered that the patient who is suffering from 
this form of paralysis is not receiving the proper amount of 
oxygen at any time, and to have air excluded even for an in- 
stant is much more dangerous than in one whose blood is 
thoroughly oxygenated at the time ; on the other hand, it is 
surprising how slight an amount of air is required to sustain the 
life of these poor sufferers. 

When applying electricity to the larynx of one suffering 
from abductor paralysis, it is well to use a very weak current, 
and to place the electrode on the muscle itself, namely, directly 



THERAPEUTICS OF LARYNGEAL PARALYSES. 365 

to the back of the larynx, in the lower part of the pharynx. 
This can be clone with a negative laryngeal electrode, guided 
by a laryngeal mirror. The positive pole may be held in the 
hand, or placed on the neck over the course of the recurrent 
nerve. The tip of the insulated laryngeal electrode is of metal, 
either unguarded or covered with a little piece of chamois-skin ; 
if the former, it should be heated in the hand or dipped into 
hot water before introducing it into the larynx ; if the latter, it 
should first be moistened in warm salt water. 

As a rule, the application should not be continued longer 
than two or three seconds ; at least, not until the larynx has 
become quite tolerant of the contact of the instrument. J. 
Mount Bleyer (N. Y. Med, Jour., November 7, 1891) advises 
that electricity be applied to the larynx by means of specially 




Fig. 110.— Author's Modification of Mackenzie's Laryngeal. Electrode. 

insulated tubes, made after the pattern of O'Dwyer's, and intro- 
duced in the same way. The chief advantages claimed are : no 
continual spasm, steady flow of current, ample time for applica- 
tion, free respiration, easy technique, and no illumination needed 
during application. 

In some cases the external application assists in restoring 
muscular tone. One pole should be placed on each side of the 
larynx, as nearly as possible over the region of the affected 
muscles, reversing the direction of the current from time to 
time. Semon recommends the application of the electrodes to 
the sides of the head, thus acting upon the phonatory centres. 
Either the faradic or galvanic current may be employed, although 
the former is usually selected. 

In post-diphtheritic and other paralyses of the superior 



366 DISEASES OF THE NOSE AND THROAT. 

laryngeal nerve, with upright epiglottis and loss of laryngeal 
sensation, electricity, manipulation, exercise, good food, and 
fresh air will go far toward a cure, but some remedy should be 
given internally; those most useful are caust, gels., mix vom., 
and strych. If there be much trouble in deglutition, it may be 
necessary to feed the patient through an oesophageal tube, that 
food may not pass into the larynx. Care is required that the 
feeding-tube be not passed through the insensitive larynx and 
augment the original clanger ; this can be obviated by pressing the 
tip of the tube well against the postero-lateral wall of the pharynx, 
with the index finger introduced over the tip of the epiglottis. 

Paralysis resulting from cold or rheumatism may be 
treated as suggested under the various forms of catarrhal 
laryngitis. 

In cases of abductor paralysis after the performance of 
tracheotomy, the patient will find great difficulty in speaking, 
on account of the escape of air from the cannula, instead of its 
passage through the glottis ; in order to obviate this he may 
either hold his finger over the outer end of the cannula while 
speaking or use a pea-valved tracheotomy-tube. With the 
latter the air will pass in through the opening valve and out 
through the glottis, as the exhaled air forces the pea into the 
open valve. In this way the tensely approximated bands may 
be set into vibration : during ordinary respiration the bands are 
not tensely drawn and the air passes out freely. If a cure be 
effected, the tube may be discarded : such a favorable result has 
sometimes followed even after division of the nerve. 

The remedies will be found under " Neuroses of the 
Pharynx " or " Diphtheria of the Pharynx and Larynx." 

FUNCTIONAL, NERVOUS, OR HYSTERICAL LARYNGEAL PARALYSIS 

(aphonia). 
This is a non-organic phenomenon which usually occurs 
in those who are nervous or hysterical, although it occasionally 
-attacks persons who seem devoid of such symptoms. Females 



FUNCTIONAL PARALYSIS. 367 

from fifteen to forty-five years of age, chiefly at puberty and at 
the menopause, are most frequently affected ; yet persons of all 
ages and of both sexes may become the victims of functional 
aphonia, There is usually no detectable pathological change, 
and if the patient can be made to believe that she can speak 
aloud, the aphonia will often pass away instantly. 

Etiology. — Functional paralyses are usually due to nervous 
influences, fright, grief, disappointment, etc. ; yet some are the 
result of a weak, lowered general vitality, consequent upon 
severe or long-lasting illness, vocal strain, loss of animal fluids, 
anaemia, amenorrhcea, or other uterine disorder. Of the 
maladies coming within the etiological category, none hold a 
more constant relation to the affection than do the early stages 
of phthisis ; therefore, when a case of functional aphonia comes 
under the physician's notice, he should always consider the 
possibility of future phthisical developments. Dr. G. W. Major 
{Archives of Laryngology, January, 1882) believes that phona- 
tion on inspiration is a frequent cause. 

Symptoms. — When the voice is suddenly lost without pre- 
vious warning or even the advent of cold, the condition under 
consideration should be suspected. If, in addition, the patient 
laugh and cough in a fairly normal manner, and give a history 
of fright, grief, or previous attacks, functional paralysis of the 
vocal bands is very probably present. Instances are not rare in 
which the patient is able to sing, but will not speak. The 
aphonia may exist for days, weeks, or months ; the voice may 
return instantly or gradually ; relapses are frequent. 

Although hysterical paralysis of the vocal bands usually 
assumes this aphonic and non-dyspnceic form, it seems possible 
for it to produce a condition in which, though aphonia exist, 
threatening dyspnoea is also present, simulating paralysis of the 
posterior crico-arytenoid muscles ; in the former the voice is 
absent ; in the latter it is always present, though often hoarse. 
This is a very rare form of functional paralysis, of which I have 
seen but one example ; its existence, even, is doubted by some 



368 DISEASES OF THE NOSE AND THROAT. 

writers. Its causes are those giving rise to the aphonic variety, 
and, like it, its onset is sudden, thus varying from the gradual 
development of organic paralysis. 

Although the symptoms are occasionally so severe that 
preparations have been made to perform tracheotomy, relief has 
occurred without operation. It is to be differentiated from spasm 
by the absence of complete and sudden closure of the glottis, and 
from paralysis of the abductors by the use of an anaesthetic, when 
the functional paralysis will at once disappear. If the laryn- 
geal mirror be used, the bands will be seen close together, both 
in the functional and organic palsy, but in the former there will 
not be that absolute loss of motion of the arytenoid cartilages, 
as occurs with the latter affection; these little indicators move 
slightly toward the median line during attempted vocalization 
and from it during inspiration. 

The laryngoscopic picture of the usual form of functional 
paralysis is characteristic ; the bands are normal in appearance, 
but widely separated, and do not often come together during 
attempted vocalization, although they usually move toward 
each other ; this is an impossibility in organic paralysis of the 
adductor muscles. During ordinary respiration the bands 
appear in their normal positions and move during the respira- 
tory act ; but on forced inspiration they often move slightly 
toward the median line. In some cases they come together on 
attempted vocalization, but with so little force as to be separated 
by the expiratory current before a tone is produced. 

Prognosis. — This is usually good, but the loss of voice may 
persist for years, or prove a precursor of laryngeal phthisis. 

Treatment. — The management of functional aphonia is often 
mental, or, rather, psychical, and everything is to be done to 
assure the patient that the voice will return in a short time. It 
is often restored under conditions similar to those which caused 
its loss ; namely, fright, fear, etc. The most efficient treatment 
is electricity. The negative pole of a rather strong faradic cur- 
rent is to be applied to the interior of the larynx ; the positive 



THERAPEUTICS OF FUNCTIONAL PARALYSIS. 369 

pole to the palm of the hand or to the surface of the neck. It 
is important that a decided shock be given, as this is often suf- 
ficient to restore the voice instantly. If necessary, the elec- 
tricity may be repeated daily. Dr. W. E. Casselberry, of 
Chicago, has recently cured two very persistent cases by gal- 
vano-cauterization of enlarged turbinateds, basing this action 
on the existence of the special reflex relationship between the 
sensory filaments of the nares and the motor nerves of the 
larynx {Med. Neivs, February 22, 1890). In some obstinate 
cases external manipulation has proved curative ; in others, 
vocal drills, beginning with the vowels, preferably preceded by 
an s or an aspirated h ; later, simple words or phrases may be 
sounded. The use of copper and other metal collars has its 
advocates. Suggestion during the hypnotic state has succeeded 
after failure of the ordinary means. In recent cases, the intro- 
duction of the laryngeal mirror may restore the voice, and 
equally good results often follow astringent applications to the 

larynx. 

Therapeutics. 

Aeon. — Aphonia due to fright, fear, anger, etc. 

Cocculus, ignatia, nat. mur., phos., stan., functional aphonia 
from mental emotion or fatigue. 

Collin, "tincture promptly cured an obstinate case of one 
year's duration after resisting the usually approved methods, in- 
cluding galvanism and change of air. The remedy was pre- 
scribed on account of rectal symptoms following a severe labor." 
(J. H. Marsden, Trans. Homceo. Med. Soc. Pa., 1882.) 

Gels. — Loss of voice, dryness, and burning caused or ag- 
gravated by emotions. " Loss of voice during menstruation." 
(Meyhoffer.) 

Ignatia. — With mental anxiety and spinal symptoms. Ner- 
vous, hysterical persons. 

Lach. — With tenderness of larynx to touch. 

Nux mos. — With gastro-intestinal and cardiac disorders. 

Phos. — Aphonia worse during the evening ; larynx very 



370 DISEASES OF THE NOSE AND THROAT. 

sensitive; anaemia of laryngeal lining; threatened phthisical 
cases ; vocal bands relaxed. 

Sepia. — In non-hysterical females; aphonia reflex from 
uterine disorders. 

Stram. — From great mental excitement ; hysteria,even mania. 

Compare bell., mix vom., platina, puis., and rhus tox. 

Spasmodic Affections. 

laryngeal vertigo (charcot) laryngeal epilepsy (l. c. gray) 

ictus larynge (krishaber) complete glottic spasm of 

adults (mcbride) — laryngeal syncope (s. t. armstrong). 

This condition, the origin and pathology of which are still 
open questions, was first described as a special condition by 
Charcot, in the year 1876 (Comptes Rend. Soc. de Biol.); 
according to this authority it " is an analogue of Meniere's dis- 
ease." With one exception, — a widow of 47 years, — it has only 
been observed in men over 25 years of age. 

Judging from the number of reported cases of this disease, 
one would be led to believe that it is infrequent, but when it is 
remembered that some of the reported cases have come to light 
by accident, the patient having given little thought to the occur- 
rences, it is most probable that the condition is not so rare. 

Etiology. — The direct causes of this affection are not very 
well known. It is ascribed by most observers to the neurotic 
state, but by some to an epileptic condition, while others are of 
the opinion that it is reflex from the vagus. It is well proved 
that a similar condition is occasioned by forcible efforts to 
expel air from the overinflated lungs while the glottis is closed, 
as described by Weber in " Midler's Archives," 1851. Sur- 
prise, anger, probable neurosis, overindulgence in stimulants or 
food, and foreign body in the pharynx are among the appar- 
ently direct causes. Remotely, the affection has been attributed 
to gout, rheumatism, snuff, tobacco-smoking, emphysema, vari- 
ous chest affections, syphilis, and bullet wound on the head 
without apparent pressure. Whatever the cause, nearly every 



LARYNGEAL VERTIGO. 371 

recorded case has had pharyngitis, usually follicular in form, and 
generally associated with congestion or hyperemia of the larynx. 
Nasal reflexes and varix at the base of the tongue and upper 
part of the larynx may act as excitants. 

Symptoms. — The first symptom immediately preceding the 
seizure is a tickling in the larynx, followed by cough ; at the 
same time there is usually a sensation of burning in the same 
region ; but in one case these two symptoms were replaced by 
a feeling as if the throat were "squeezed together." Preceding 
the attack there is sometimes an irresistible impulse to seize the 
larynx with the hands. Although the other symptoms be 
absent, cough never fails to make its appearance, and it would 
seem that the sudden prevention of the impulse to cough is the 
precipitating cause of the seizure. In very mild cases stridulous 
cough may be the sole manifestation of the affection ; or, after 
two or three such coughs, the seizure may occur at once, followed 
by a sensation of suffocation or of slight laryngeal spasm. Some 
patients complained that " all the muscles of respiration were 
arrested." The cough may be severe and paroxysmal, but is 
usually slight ; in the second or third attempt the glottis refuses 
to open, and the patient immediately feels giddy. As a rule, he 
falls, and loses consciousness for a few seconds or minutes, 
although he may be conscious throughout, even though he fall. 
During the attack there is no biting of the tongue, rarely mus- 
cular twitchings, no urine is voided, and only in a few instances 
have there been slight convulsive movements. There is no cry 
preceding the loss of consciousness. Loss of memory has been 
noted in some cases. 

In one case (McBride) there was exaggerated tendon-reflex, 
ankle-clonus, spasmodic action of the palatine muscles, and 
occasional spasmodic stricture of the oesophagus. The face is 
either pale, suffused, or swelled during the attack. The seizures 
may occur every few months, or as often as three or four times 
during the day. I have not seen any recorded case in homoeo- 
pathic literature, but I have treated one man of 30 years, in 



372 DISEASES OF THE XOSE AND THROAT. 

whom the attack came on without any known cause. Tickling 
in the larynx, cough, and a sense of impending suffocation were 
speedily followed by a sensation of dizziness and partial uncon- 
sciousness, but he did not know that it was ever complete. 
Under the use of hyos. 30 x he recovered in about four months. 
Although there was slight follicular pharyngitis, it was not 
specially treated. 

Prognosis. — The prognosis is good, as no case reported has 
failed to be relieved in a very short time, and all save two of the 
recorded cases were cured. In the first of these, the man died 
as the result of concurrent asthma ; in the second, the patient 
did not remain under observation sufficiently long to give an 
opportunity for cure. As the symptoms, however, may be mis- 
taken for cardiac failure, or even apoplexy, it is not improbable 
that fatal results may have thus been overlooked. 

Treatment of the pharynx alone, or of the larynx as well, 
is attended with good results. In the majority of recorded cases 
bromides were employed, and in some counter-irritation was ap- 
plied over the larynx. Measures should be directed to any nasal 
or pharyngeal alteration, including elongated uvula and lingual 
varix, which might act as a predisponent to laryngeal vertigo. 

Symptomatically, one would be led to expect relief from 
the use of bell., bromine, chlorine, cuprum, iodine, moschus, or 
verat. vir., but the prompt action of hyos. in the case noted 
should prove the efficacy of this remedy. Moschus has one 
very strong characteristic, namely, sudden sensation as though 
the upper portion of the larynx closed upon the breath. 

Tobacco and alcoholic stimulants should be avoided. 



PHOXATORY SPASM SPASM OF THE TEXSORS OF THE VOCAL 

BAXDS (MACKENZIE) STAMMERING OF THE VOCAL BANDS 

(PROSSER JAMES) CHOREA OF THE LARYXX APHONIA AXD 

DYSPHONIA SPASTICA. 

Etiology. — This rather rare condition arises as the result 
of overuse, abuse, or, more correctly, improper use of the voice, 
and is often found in habitual drinkers of alcoholics. It is due 



CHOREA OF THE LARYNX. 373 

to some disturbed co-ordination of the vocalizing muscles, and 
usually occurs in those who use the speaking voice in public. 
I have never seen such a condition in a singer. From the 
etiology it will be seen that men are the chief sufferers, and no 
class is so liable to the affection as clergymen, who are fre- 
quently at fault in their methods of voice production. 

Symptoms. — The condition manifests itself in irregular, 
jerky tones, often very weak and almost inaudible. The tones 
may be nearly normal for a time, but the defect soon recurs. 
The patient sometimes complains that the words will not come ; 
the lips move, but no sound is heard. In other instances the 
glottis is closed to the exit of air and relaxation does not occur 
until the effort at vocalization is discontinued. In the mean- 
time cyanosis may occur, accompanied by pain in the larynx 
and chest. The phenomenon is rarely present during whisper- 
ing. Articulation is seldom affected. 

Inspection. — The laryngoscope may show little or no path- 
ological change, but the laryngeal mucous membrane is occa- 
sionally congested as a result of the faulty vocalization. The 
more intense the spasm, the closer the bands are coapted. If 
the lateral crico-arytenoids be the only muscles involved, there 
is a slit of considerable size nearly representing the normal 
vocalizing glottis ; but if, in addition, the arytenoideus be con- 
tracted, the glottis is closed throughout. Prosser James, who 
described this phenomenon in 1879 ("Sore Throat"), gives the 
following : " The vocal cords hesitate or tremble for an instant 
at a point not sufficiently approximated for vocalization, where 
they move as with a series of ineffectual efforts to obey the will, 
or display the paroxysmal, spasmodic, or irregular actions seen 
in the mouths of confirmed stammerers, or the less distinct 
interferences with utterance called 'hesitation of speech.' " 

Prognosis. — The prognosis is not absolutely bad, as I had 
one case recover. The late Sir Morell Mackenzie wrote : " The 
disease is nearly incurable ; " and Schech is of a similar opinion. 

Treatment. — The treatment consists in the use of cuprum, 



374 DISEASES OF THE NOSE AND THROAT. 

hyos., ignatia, or mag. phos. internally, and in local bathing 
with cold salt water, followed by brisk rubbing night and morn- 
ing, massage of the laryngeal region, a good supply of fresh 
air, free exercise, nasal respiration, hypnotic suggestion, and 
galvanism ; but, above all, in a careful training under the guid- 
ance of some intelligent, judicious, capable "voice builder." 

Mogiphonia (B. Frankel) is a condition not unlike that 
just described, and is analogous to writers' cramp. The ordi- 
nary speaking voice is unaffected, but professional speaking or 
singing is at first difficult and painful, and later impossible. 
During the attack the vocal bands seem to lack regular tension. 

The prognosis and treatment are practically those of phonic 
spasm. 

SPASM OF THE LARYNX. 

This title covers all the names which have been given to 
the condition for centuries. They include : Spasmus glottidis, 
Spasm of the Glottis, Laryngismus Stridulus, Child Crowing, 
Asthma Millari, Asthma Koppii, Asthma Thymicum, etc. This 
phenomenon is without any laryngeal inflammation or febrile 
action ; hence it must not be confused with spasmodic or false 
croup (stridulus laryngitis, subacute laryngitis). 

It consists of the sudden, complete, and more or less pro- 
tracted paroxysmal closure of the glottis, due to stimulation of 
the recurrent or vagus, either directly or reflexly. The condi- 
tion may arise at any time from birth to extreme old age, but 
as its manifestations are not identical in persons of all ages it 
is deemed advisable to consider it under two headings, namely, 
" Laryngeal Spasms of Children " and " Laryngeal Spasms of 
Adults." 

LARYNGEAL SPASMS OF CHILDREN. 

Etiology. — These spasms usually occur in poorly-nourished 
children under two years of age. They generally appear in con- 
nection with cerebral and gastric irritation, microcephalus, 
hydrocephalus, rickets, and enlarged glands, particularly the 



LARYNGEAL SPASMS OF CHILDREN. 375 

post-nasal, cervical, bronchial, thymus, and thyroid. Flesch, of 
Frankford {Inter. Idin. Rundsch.), has always found, post- 
mortem, two hard glands on the left recurrent nerve. Goodhart 
considers as a cause excessive recurving of the epiglottis in its 
vertical axis, as if bent in half down the middle, thus bringing 
the ary-epigiottic folds nearly into apposition. Ringer suggests 
an elongated and thickened uvula. Phimosis, paraphimosis, 
and rectal, aural, and nasal irritation are occasional causes. 
Hereditary influence is doubtful. Among the general exciting 
causes, malnutrition stands most prominent ; next in frequency 
comes intestinal irritation, either in the form of irritating, non- 
digested food, constipation, or parasites. Fright, fear, and the 
accidental entrance of food and other foreign substances into the 
larynx are not unusual excitants. Laryngeal spasms occur more 
frequently in hand-fed children than in those who are nursed by 
the mother. Boys are more frequently affected than girls, 
perhaps on account of the greater exposure of the former. 
Laryngeal spasms are most frequent in winter and spring ; first 
dentition is the time of life most liable to the affection ; it rarely 
occurs after the eighth year. Illy- ventilated and insanitary 
houses favor the affection, as do lack of proper exercise and 
fresh air. 

Pathology. — Pathologically there is little to note, as the 
condition is a nervous reflex, the lesion usually existing in some 
remote part of the body, as has already been stated. In some 
fatal cases there have been found congestion, hypersemia, oedema, 
and exudation of the brain. In a few post-mortems solitary 
glands of Peyer's patches and the mesenteric glands have been 
found enlarged ; in others, the autopsy has shown slight emphy- 
sema, oedema, chronic pneumonia, or perhaps tuberculosis of 
the lungs. As previously stated, the larynx shows little or, more 
frequently, no pathological change, and there are no indications 
of an impending laryngeal spasm. 

Symptoms. — The symptoms of the attack are so tersely and 
graphically described by Gottstein, in his " Die Krankheiten 



376 DISEASES OF THE NOSE AND THROAT. 

des Kehlkopfes," that it will be well to quote them : "Suddenly, 
after one or two short, whistling inspirations, respiration ceases, 
owing to closure of the glottis. The anxious countenance, the 
staring eyes with contracted pupils, the pale skin, blue lips, 
dilated nostrils, the head bent backward, while the neck is ex- 
tended and the brow covered with cold perspiration, show how 
sharp has been the struggle for breath. After a short time, 
lasting from a few seconds to two minutes, which, however, 
seems an eternity to the on-lookers, if death by suffocation do 
not occur during the paroxysm, the painful scene is ended by 
several deep crowing inspirations. The respiration, at first rapid 
and deep, soon resumes its regular rhythm, and gradually the 
child returns to its normal condition." Following severe parox- 
ysms the patient is much fatigued. 

It must not be supposed that all seizures are so severe, for 
many times they are little more than " breath catchings," so 
transient as to attract but little attention, until a severer attack 
denotes the danger. On the other hand, the condition may 
never show itself in the milder form, even the first paroxysm 
proving fatal. 

In addition to the respiratory symptoms noted, it is quite 
usual for other parts of the body to share in the spasm ; thus, 
the fingers and hands may be contracted, the fingers stiffly ex- 
tended, the thumbs, wrists, and feet turned inward, the toes 
tightly contracted, and the lower extremities flexed with opis- 
thotonos or tonic convulsions of the entire body. Carpo-pedal 
convulsions have rarely been noted after the fifth year. Con- 
sciousness is usually lost in severe cases, but not in the milder 
attacks. The heart's action is much disturbed ; at first strong 
and quick, it becomes weaker and very irregular until it ceases 
altogether. The temperature, in the few cases in which it has 
been recorded, varied from 98.5° to 98° F., and in severe cases 
even to 96.5° F. 

Dr. Cheyne considers as pathognomonic of this malady, " a 
crowing inspiration, with purple complexion, not followed by 



LARYNGEAL SPASMS OF CHILDREN. 377 

cough" The spasm may be a single one with no recurrence ; 
it may be repeated many times a day and recur on many con- 
secutive days, or it may assume a chronic form and persist, with 
intermissions, for weeks or months, or until the removal of the 
morbid cause, which at once restores the lost nervous balance. 

Diagnosis. — It is important to distinguish spasm of the 
larynx from membranous croup ; if, however, the history of the 
case be considered, there can be but little possibility of confusing 
the affections. False croup is devoid of expiratory difficulty, 
and there is sudden and complete relief as soon as the spasm 
relaxes ; hoarseness usually persists, fever may be present, 
and there is a laryngeal catarrh ; further, spasmodic croup is a 
nightly visitor, while laryngismus stridulus occurs only during 
waking hours. It differs in its history from bilateral paralysis 
of the abductors of the vocal bands ; the latter condition is 
usually found in middle-aged or elderly persons ; it makes its 
appearance slowly, the breathing is impaired at all times, but is 
aggravated by any exercise or excitement, and is often increased 
and noisy during sleep ; neither is there complete closure of 
the glottis without previous warning, as occurs in the spasmodic 
affection. Acute laryngitis and oedema of the larynx appear 
slowly in comparison with spasm, and there are severe cough, 
fever, and local disturbances for some hours or even days before 
the onset of the dyspnoea. If the laryngoscope can be used, 
there is no difficulty in differentiating it from membranous 
laryngitis by the absence of membrane ; from subacute laryngitis 
by the absence of inflammation ; from acute laryngitis by the 
absence of inflammation, swelling, or oedema ; from acute 
oedema of the larynx by the absence of dropsy; and from 
paralysis of the glottis-openers by the absence of constant partial 
closure of the glottis. Whooping-cough has spasms after the 
first week of the attack; spasms of the larynx at the onset. 

Prognosis. — Although the spasm sometimes results in death 
from apnoca during the attack ; from coma, due to effusion, the 
result of obstruction to the return circulation in the brain ; or 



378 DISEASES OF THE NOSE AND THROAT. 

from exhaustion following the paroxysm ; the prognosis cannot 
be considered very grave, in that most cases recover even after 
severe seizures. Where there are general spasms, however, 
when very frequent, or where the brain is implicated, the prog- 
nosis is to be more guarded. It is said that the results are 
more favorable in girls than boys. The younger the child, the 
lower the temperature during the attack, and the more marked 
the general convulsions, the worse the prognosis. It is likewise 
worse in the poorly nourished, the rachitic, and the scrofulous ; 
and better the older the child and the greater the interval 
between the attacks. 

Treatment. — The physician is rarely present during the 
attack, but directions should be left in anticipation of other 
seizures ; the windows should be opened to secure a bountiful 
supply of fresh air ; the child placed in a sitting posture with 
the body bent forward, the large toes and thumbs flexed, sensi- 
tive regions of the body pinched, especially the inside of the 
thighs and arms; the back should be struck with the palm, and 
the surface of the body thoroughly rubbed, either with the bare 
hand or with mustard or alcohol. Some advise the inhalation 
of ammonia, but it is possible that its effect may be contrary to 
that intended. Ether and chloroform act well, and, if carefully 
employed, nitrite of amyl is a valuable adjuvant. Rival 
reflexes, as retching and vomiting, may break the spasm ; these 
may be excited by tickling the fauces with the finger or a 
feather : the tip of the epiglottis may be elevated with the finger 
(see report of a case by E. H. Gregg, Hahnemannian Monthly, 
September, 1892) or the nasal mucous membrane may be 
excited by snuff or a feather. Any tight or constricting bands 
of clothing should be loosened at once. When these measures 
fail to resuscitate the patient, cold water may be forcibly 
syringed against the ensiform cartilage in order to stimulate the 
phrenic or pneumogastric nerve, and electricity may be applied 
for the same purpose. The positive pole should be placed over 
the spine and the negative on the hypogastrium. If these 



LARYNGEAL SPASMS OF ADULTS. 379 

means fail and death seem imminent, an intubation tube or 
English catheter should be passed through the glottis. In the 
absence of these instruments the surgeon may perform a hasty 
tracheotomy even with his pen-knife. If after any of these 
operations the patient do not breathe at once, it will be neces- 
sary to resort to artificial respiration, or to the ordinarily 
employed resuscitative measures. 

In the interval of the attacks the child should be placed in 
the very best hygienic condition, both mental and physical ; 
tight clothing should be discarded ; fright, fear, startling, sudden 
waking from sleep, excitement, worry, severe exercise, and con- 
stipation should be guarded against. Good, nourishing diet 
and plenty of mild exercise in the pure, fresh air are important 
elements in successful treatment. The child should be fed in 
small quantities at frequent and regular hours, as overdistension 
of the abdomen, resulting from large and infrequent meals, with 
consequent pressure on the pneumogastric terminals, is apt to 
excite an attack ; the food, too, should be of a non-irritating, 
readily digestible nature. Codliver-oil or terraline often acts 
well by affording condensed nourishment. 

Mild sponge-baths followed by brisk rubbings are useful in 
promoting good circulation ; the water must not be dashed upon 
the child, neither should he be put into a tub of water, lest a 
paroxysm be excited. The treatment of the exciting cause is of 
the greatest importance ; it is not necessary, however, to detail 
it here, as it will be found in works on general medicine and 
surgery. 

LARYNGEAL SPASMS OF ADULTS. 

Etiology. — These are rare, if we exclude pressure from 
enlarged glands, tumors, or foreign bodies within the larynx. 
The most frequent element in the etiology of this neurosis is 
hysteria, but epilepsy, tetanus, hydrophobia, chorea, laryngeal 
vertigo, locomotor ataxia, sexual excesses, and uterine derange- 
ments are not unknown incitors to laryngeal spasms of adults. 
In some instances no cause can be ascribed, when, perhaps, the 



380 DISEASES OF THE NOSE AND THROAT. 

attacks are to be partially attributed to the peculiarly nervous, 
morbid irritability of the individual. 

Symptoms. — Spasms of the larynx in the adult differ some- 
what from the same affection when occurring in children, in that 
in the former the closure of the glottis is not so decided nor so 
frequent as in the latter. The adult glottis often presents partial 
closure ; the attempts at inspiration are very noisy, deep, and 
whistling, while expiration is short and loud. The paroxysm 
is attended with the greatest anxiety. It is probable that the 
general convulsions which accompany these manifestations are 
secondary to some systemic disorder rather than to the effect of 
the laryngeal spasm, as they occur chiefly in hysterical individ- 
uals. Gottstein had the unusual good fortune to examine the 
larynx in one case during the attack. He thus describes the 
appearance: "We found the cartilaginous portion of the glot- 
tis firmly closed, the points of the vocal processes somewhat 
prominent, and the ligamentous portion of the glottis closed, 
with the exception of a narrow cleft ; contact of the ventricular 
bands did not take place." 

The affection may be confused with the graver one of 
abductor paralysis, but the laryngoscope will reveal the free 
motion of the vocal bands during the intervals of the paroxysms; 
and the dyspnoea due to spasm is intermittent. 

Prognosis. — The prognosis is good, as a rule, but fatal cases 
are on record, the result either of asphyxia or exhaustion. The 
condition may pass away at once or persist for weeks, the 
paroxysms recurring frequently. 

Treatment is essentially the same as that described under 
" Laryngeal Spasms of Children," but intubation and trache- 
otomy are rarely necessary. The remedial treatment of the two 
conditions is given below. 

Therapeutics. 

Ars. iod. does excellent service when the child is restless 
and uneasy, has sore mouth, a disposition to looseness of the 
bowels, skin easily chafed, and the food often vomited. 






THERAPEUTICS OF LARYNGEAL SPASMS. 381 

Bell. — Even a sip of water induces spasm ; larynx painfully 
dry ; cerebral excitation ; face red, eyes injected, skin hot and 
dry ; and reflex irritations. 

Bromine. — At first the voice is deep and rough ; later 
aphonic. Hasping, whistling breathing, or rattling of mucus in 
the larynx. Reflex from stomach, teeth, or enlarged thymus 
gland. 

Calc. carb., "doubtless, occupies the most prominent place, 
and is especially indicated by the early symptoms, such as late 
teething, broad fontanelles, perspiration about the head, light 
stools, curdy movements, and restless nights. Should the child 
be of a scrofulous diathesis, with a tendency to accumulate fat, 
and yet with the ordinary expression of health, this remedy 
would be more strongly demanded." (Dr. Sheldon Leavitt, The 
CUnique, September 15, 1890.) 

Chlorine seems, according to Dunham, Searle, and Nichol, 
to be chiefly indicated when expiration is more difficult than in- 
spiration ; with overfilled air-cells, livid lips, and unconsciousness. 

Chlor. water 3 x and naphthalan act, according to J. P. 
Cobb, as palliatives. He further finds calc. iod. to give satisfac- 
tion where laryngismus stridulus is associated with enlarged 
glands {The Clinique, September 15, 1890). 

Cuprum. — General as well as local spasms; clenched 
thumb, vomiting after the attack (Bsehr) ; cold perspiration at 
night (W. S. Searle) ; or when the spasm is incidental to other 
diseases ; for example, croup or whooping-cough ; and inspira- 
tion more difficult than expiration (Nichol). Attack produced 
by fright (C. P. Hart). 

Gels, is best used as a palliative in drop doses of the tinc- 
ture every five minutes until relief is assured ; or, it may be 
used curatively in the 6 x dilution (10 drops in as many tea- 
spoonfuls of water ; a teaspoonful every two hours) where there 
are acute nasal catarrh and laryngeal and tracheal tenderness. 
Long, crowing inspiration, followed by a sudden, forcible expira- 
tion. There is often profuse perspiration with a darkly-flushed 
face. 



382 DISEASES OF THE NOSE AND THROAT. 

Hyos. — Hysterical spasm ; severe dyspnoea, worse lying ; 
aphonia ; dry, nervous cough. 

Ignatia. — If the attack can be traced to hysteria, excite- 
ment, or a scolding. 

Iodide of lime, calc. carb., and calc. phos. are to be carefully 
considered in those cases where malnutrition, rickets, tabes 
mesenterica, and similar conditions act as the foundation-stone 
upon which rest the various phenomena of laryngismus stridulus. 

Iodine. — For the acute attacks and in the intervals when 
there are rickets, scrofula, and enlarged and indurated tonsils, 
cervical, thymus, and bronchial glands ; tendency to marasmus 
with good appetite. Tightness and constriction about the 
larynx ; hoarseness and soreness. 

Ipecac is rarely useful except when the result of asthma 
[nasal] or catarrh (Bsehr), or when associated with whooping- 
cough. Face blue and extremities cold. 

Lach. is to be used according to its throat symptoms ; the 
sensitiveness to contact, the aggravation on awaking or follow- 
ing sleep, etc. 

Sambucus. — " The child suddenly awakened, nearly suffo- 
cated ; sits up in bed and turns blue ; gasps for breath, which 
it finally gets; the spell passes off; it lies down again in bed, 
but to be aroused, sooner or later, in the same manner." 
(" Guernsey's Obstetrics.") " Is able to inhale, but not to 
exhale; becomes livid in the face." (C. Wesselhceft.) Burn- 
ing, dry heat of surface during sleep; perspiration while awake. 

Compare aeon., ars. alb., bell., calc. phos., coral rub., me- 
phitis, plumbum, and verat. alb. 

NERVOUS LARYNGEAL COUGH. 

Etiology. — This affection is characterized by a spasmodic, 
paroxysmal, sharp, metallic, and ringing cough. It is caused 
by various reflexes ; nasal, tonsillar, pharyngeal, and thyroid 
irritation ; pharyngeal varix and catarrh ; gastric and intestinal 
derangements ; uterine and ovarian disorders ; hysteria ; chorea ; 
and so-called neurasthenia. 






REMEDIES FOR THE VOCAL DEFECTS OF SINGERS. 383 

Symptoms. — As a rule, the laryngoscopic picture is normal, 
cough being the only symptom of any prominence. This phe- 
nomenon makes its appearance in paroxysms of two, three, or 
more coughs ; or the attack may last for many minutes, or even 
hours, with little cessation, terminating only with the utter ex- 
haustion of the individual, who often falls asleep directly after. 
The cough may occur at night only, and keep the patient awake 
for a long time. It is observed in persons of both sexes and of 
all ages, but is more frequent in hysterical females, and is very 
rare before the eighth year. The periods of puberty and the 
menopause furnish many examples. 

Prognosis. — The prognosis is good, but a dure is often very 
difficult, as the cough may persist for many months or even 
years, disappearing for a time and again returning. It some- 
times creates intense laryngeal spasm, and, in one case recorded 
by Mackenzie, it was necessary to resort to tracheotomy. 

Treatment. — The treatment of nervous laryngeal cough 
depends upon the presumed cause. The various nasal reflexes 
should be tested, the nasal passages thoroughly searched for 
polypi, and the general condition carefully noted, — all of which, 
if possible, should be corrected. At times it is found advisable 
to use tonics, but in all cases careful search should be made for 
the similimum. 

Of the internal remedies, dros., hyos., and mag. phos. are 
most frequently useful. A solution of chloride of zinc (gr. x) 
and glycerin (gj) is often efficient when applied to the naso- 
pharynx. An ocean voyage is a universal palliative. There 
are many points of resemblance between pertussis and nervous 
laryngeal cough, which need scarcely be considered here. 

REMEDIES FOR THE VOCAL DEFECTS OF SINGERS. 

Antim. crud. — Loss of voice when overheated by exertion 
(fatigue), but returning with rest. 

Argent, met. — " Alteration in the timbre of voice of singers, 
speakers, and preachers, with feeling of constriction and rawness 
in the larynx." (Lilienthal.) 



384 DISEASES OF THE NOSE AND THROAT. 

Arn. — Hoarseness from fatiguing use of the voice. " Hoarse- 
ness of preachers and military officers, from long preaching and 
commanding ; also of conductors from calling out the railway 
stations." (Hering.) 

Arum tri. — Hoarseness from overuse or abuse of the voice, 
especially from speaking in a high key ; lack of control over 
the vocal bands ; the pitch suddenly changes. In attempting 
loud speech the voice ends in a squeak. The late Dr. Lippe 
recommended arum tri. for opera-singers who are hoarse and 
who must sing within four or five hours. 

Caust. — Ploarseness or aphonia from singing or public 
speaking. This acts as a toner of the vocal muscles when given 
a few hours before singing or public speaking. 

Coca. — As an instantaneous toner-up (fer. phos. and popu- 
lus can.), to be given in 5-drop doses of the tincture or of the 
Mariani wine a half-hour before singing or speaking. 

Fer. phos. — Painful hoarseness from overuse, or, more 
especially, abuse or strain in speaking or singing (arn.). 

Gels. — Hoarseness and aphonia from paresis of laryngeal 
muscles ; cannot produce a loud tone (caust.). 

Graph. — Very similar to arum tri. " It is an excellent 
remedy to give singers when they cannot control their vocal 
cords ; when they get hoarse as soon as they begin to sing and 
the voice cracks." (Farrington.) 

Hepar. — Overuse or strain produces hoarseness or aphonia 
and resultant laryngeal pain, soreness, congestion, and inflam- 
mation. This remedy often restores the lost timbre. 

Kali phos. — Fatigue and hoarseness from overuse or abuse 
of the voice, particularly in debilitated and rheumatic patients 
(arum tri. and rims tox.). 

Populus can. — Acute hoarseness preventing song ; pharynx 
and larynx feel dry. The voice is weak, toneless. 

Rhus tox. — Tired, aching in larynx, with hoarseness or 
aphonia from prolonged or severe use of the voice ; also, more 
hoarse after long rest, especially on waking ; better after short 
use. 



REMEDIES FOR THE VOCAL DEFECTS OF SINGERS. 385 

Selenium. — The voice becomes hoarse as soon as singing 
or speaking begins ; expectoration of transparent mucus from 
the larynx in the morning. "Very valuable for the hoarseness 
of singers, especially when it is frequently necessary to clear the 
throat of clear, starchy mucus (compare stann.)." (T. F. Allen.) 

Senega. — Sudden aphonia from vocalizing ; throat very 
dry; feels like a feather, or as though it had been pricked, 
which induces a single dry cough and often causes momentary 
lachrymation (clinical). 






CHAPTER XXIX. 

Inflammatory Affections. 



SUBACUTE LARYNGITIS. 

Subacute laryngitis, as here considered, is an affection 
in which the mucous membrane alone is involved; the under- 
lying structures not being affected, as in acute laryngitis. 

Etiology. — The chief causes of subacute laryngitis are 
chilling ; rapid surface-evaporation ; exposure to draughts of 
air, either warm or cold, especially when the body is over- 
heated ; a damp, chilly, or a dry, cold, dust-laden atmosphere; 
chemical fumes; tobacco-smoke; lack of fresh air and exercise; 
alcoholism ; gastric derangements ; overuse, abuse, or misuse 
of the voice, including singing in the open air ; damp feet and 
clothing ; and muffling the neck. Previous attacks often pre- 
dispose to subsequent inflammation, and the presence of chronic 
catarrh of the nose, pharynx, or larynx may, upon a slight 
exposure, determine a subacute laryngitis. A weakened vitality, 
either as the result of disease, loss of sleep, or hunger, pre- 
disposes the patient to an attack. It is more frequent in 
males than females, and in adults than children, in whom it 
often declares itself in the form of false croup. The changeable 
weather of autumn and spring is more pernicious than the more 
uniform seasons of winter and summer. The various exan- 
themata, more especially measles, scarlatina, chicken-pox, vari- 
ola, and typhoid and typhus fevers act as predisposing and 
exciting causes ; it must be remembered, however, that all of 
these, save measles, may give rise to a laryngeal affection much 
more severe than a subacute catarrh. Finally, traumatic causes 
(inhalation of flame, steam, scalding water, etc.) may induce 
subacute laryngitis. 
(386) 






SUBACUTE LARYNGITIS. 387 

Pathology. — Hypersemia is the first morbid alteration, and, 
if at all marked, may lead to swelling and secretion. The entire 
mucous lining is not usually hypersemic ; so that it is more 
pronounced in one part than another. On this account, some 
authors have described the inflammation as a disease of the 
especial portion involved. The vocal bands are not usually uni- 
formly congested, or may escape entirely ; they may remain 
unaffected after other portions of the laryngeal structure are 
involved, or suffer to the exclusion of other regions. There is 
rarely any swelling of the tissues, although the mucosa may 
appear puffy and the sharper outlines a little blurred. It is not 
rare to find a slight abrasion of the epithelium, which is some- 




Fig. 111.— Subacute Laryngitis. 

times called an ulcer, but it is doubtful if a true catarrhal ulcer 
is ever found. Stoerk has described and pictured a vertical 
fissure of the inter-arytenoid space, but few others have been 
able to discover such a change. One case which I saw at 
Professor Stoerk's clinic, in Vienna, resembled a folding of the 
mucous membrane, as frequently seen, and which almost disap- 
peared during deep inspiration. 

Symptoms. — The symptom which usually first attracts 
attention is a sensation of dryness, tickling, or burning ; soon a 
deep, weak, or shrill voice develops, accompanied, perhaps, by 
a dry cough and aphonia. At first there is no secretion, but 
later a glairy mucous discharge, which, becoming more profuse, 
is laden with broken-down epithelium. Respiration is not 



388 DISEASES OF THE NOSE AND THROAT. 

interfered with, unless reflex spasm occur or the secretions dry 
in such a position as to encroach upon the glottic space. A 
slight paralysis will occasionally be seen, chiefly of the thyro- 
arytenoid muscles. As a result, the bands are bowed, leaving an 
elliptical space ; but there may be paralysis of the arytenoideus 
and slight separation posteriorly, while a combination of these 
forms is not unusual. A slight catarrhal thickening of the 
mucous membrane in the inter-arytenoid region may interfere 
with the voice by preventing complete closure of the cartilag- 
inous glottis. Irritation of the superior laryngeal nerve may 
give rise to aphonia, but, as a rule, this is due to congestion of 
the vocal bands or inter-arytenoid commissure. Subacute laryn- 
gitis of children often occasions spasmodic attacks (false or spas- 
modic croup). The child is suddenly aroused from sleep with 
cough and difficult inspiration ; these soon subside, and he sleeps 
again, perhaps until morning, or it may be only for a short 
time, when he is again aroused. 

Prognosis. — If the treatment be at all prompt and careful, 
it is unusual for a case to do otherwise than well. On the 
other hand, if not seen early or not properly cared for, the 
condition may relapse, giving the sufferer much annoyance. 
Repeated attacks are apt to end in chronic catarrh. 

Treatment. — In the treatment of this disease the patient 
should be advised to speak but little and in a whisper. It is 
better that he remain indoors and in one room, the temperature 
of which should be kept as near 70° F. as possible. The 
atmosphere should be moistened as suggested under diphtheria. 
Although many persons recover promptly, even when obliged 
to continue their vocation, there is risk of incomplete cure and 
of relapse. Fer. phos. is one of the best remedies for the early 
symptoms and for acute exacerbations, while aeon, often serves 
a very good purpose in cutting short the attack ; but, if well 
established when first seen, some of the following remedies will 
be found to promptly cure most cases : — 



THERAPEUTICS OF SUBACUTE LARYNGITIS. 389 

TherajDeutics. 

Aeon. — In the beginning, particularly in children ; fever ; 
chilly ; dry skin ; hoarseness ; expectoration, if there be any, is 
slight, thin, and frothy. Ts awakened at night with croupy 
cough, pain in the larynx, and anxiety (compare fer. phos.). 

Bell. — Vocal bands bright-red; fullness, dryness, constric- 
tion, and soreness in the larynx ; attempted vocalization pain- 
ful ; voice husky, hoarse, or aphonic ; respiration hindered at 
times, or whistling and oppressed. 

Bromine. — Croupy cough ; husky, hoarse voice ; raw, 
scraped feeling in the larynx. 

Calc. iod. — " General hyperemia involving the vocal cords." 
(Leal.) 

Fer. phos. is usually the first remedy of which I think, and, 
if given early, it is often the only one required. It seems to 
control the inflammatory condition and hold in check the 
further progress of the disease. Dr. H. C. Houghton (Trans. 
Horn. Med. Soc. State of N. Y.\ 1886) says: "It enables singers 
to control the voice in its entire compass, by holding a disc in 
the mouth for a few minutes previous to any unusual effort, 
when suffering from hoarseness." I have frequently verified 
this statement, and have seen similar results follow the use of 
populus can., one of the greatest of temporary voice-toners. 

Guaiac. — ;i When, in laryngitis and laryngeal irritation 
without other indications, the bands are boggy, there is loss of 
tone and lustre, I use, with confidence, the tincture of guaiac. 
internally and the ammoniated tincture, 1 drachm to 1 ounce 
of water, as a spray, first suggested to me by Prof. Chas. M. 
Thomas." (Dr. Wm. R. King.) 

Hepar. — Especially in children, after exposure to dry, cold 
winds, for croupy cough and hoarseness ; throws the head back, 
worse in the morning ; very sensitive to the slightest draught. 

Nux vom. — The catarrhal attack begins in the pharynx, 
soon followed by slight fullness and tickling in the larynx ; the 



390 DISEASES OF THE NOSE AND THROAT. 

patient swallows frequently to prevent cough. The vocal bands 
are not congested at this stage, but have a dull, lustreless 
appearance, which, if not checked by a few doses of nux vom., 
soon show redness (clinical only). Indigestion and constipation 
play no small part in the etiology of such an attack. 

Phos. — Constant, tickling cough ; slight hoarseness, or 
even aphonia ; pain and roughness in the larynx, aggravated 
by cough, which results from speaking, laughing, eating, or 
drinking. Vocal bands congested, thick, heavy-looking. 

Spongia. — Burning and stinging in the pharynx and larynx ; 
sensation of a plug in the larynx, which is sensitive to touch. 
Cough, hoarseness, dyspnoea, spasm. 

ALCOHOLIC LARYNGITIS. 

This is either a subacute or a chronic affection, and can 
usually be traced directly to the habit of " moderate drinking." 
I quote from Mr. Lennox Browne, "Voice Use and Stimulants :" 
" We find that, in a certain definite proportion of singers and 
actors, whose habits are known to us to be lax with regard to 
alcohol, there is a constant disposition to congestion of the 
mucous membrane and to more or less acute inflammation, 
which often extends down the windpipe to the bronchial tubes, 
and gives rise to a constant hoarseness or huskiness in the 
speaking voice, not always perceptible in early stages in the 
singing voice ; later, we see chronic inflammation and thicken- 
ing of the tissues, especially of the lid [epiglottis], as recorded 
by Gottstein and by myself. And in a few advanced cases I 
have observed a nodular condition indicative of intrinsic degen- 
eration of the vocal ligaments themselves. These last structures 
are often seen to act tremulously and uncertainly as the patient 
phonates with the mirror in position, and' the same symptom is 
observed in their sniffing in the ordinary way. I have also 
witnessed examples of complete loss of voice (aphonia), as 
reported by Dr. Morgan, due to paralysis of the vocal muscles, 
without previous congestion or inflammation. In such cases the 



ACUTE (SUBMUCOUS) LARYNGITIS. 391 

alcohol has acted on the nerves and muscles of the larynx as a 
direct poison, producing a palsy precisely similar in character to 
that of lead, arsenic, phosphorus, or other toxic agents." 

There is a congestion of the soft palate and uvula, of a 
brick-dust color, with a rather dry, slightly wrinkled appearance. 

The treatment is to reduce the quantity of stimulants, after 
which little is usually needed. (Compare " Chronic Laryngitis.") 

ACUTE (SUBMUCOUS) LARYNGITIS. 

This affection differs from subacute laryngitis, in that it 
involves the deeper structures of the larynx (including sub- 
mucous tissue and muscles) in a severe inflammation, which 
results in a serous or bloody infiltration of the tissues, with 
encroachment upon the laryngeal cavity. 

Etiology. — The etiology is similar to that of the milder 
type of inflammation. Traumatic laryngitis more frequently 
assumes the acute than the subacute form. 

Symptoms. — The objective symptoms are very character- 
istic, but the subjective are often misleading ; thus, it is some- 
times very difficult to make an accurate diagnosis without the 
aid of the mirror. Usually the first indication is chilliness and 
a sensation of tickling, dryness, or rawness in the larynx; this 
is soon followed by a sense of fullness. A harsh cough is early 
an annoying condition ; the voice becomes husky, and is soon 
lost. Although great effort is made, no mucus is expelled ; 
impairment of the respiratory function soon follows, and deglu- 
tition becomes painful and difficult, or almost impossible. 
Pressure over the larynx is often painful, especially in children ; 
and compression, even though slight, increases or even induces 
difficult respiration. Pain is a prominent symptom, and is 
aggravated by cough, deglutition, speech, and sometimes by 
breathing. The chilly sensation is speedily replaced by a tem- 
perature of 102° to 104° F. If dyspnoea increase, the patient 
will be bathed in a cold perspiration ; he will struggle for 
breath, and the chest and throat-muscles will be thrown into 



392 DISEASES OF THE NOSE AND THROAT. 

violent action. If improvement occur at this stage dyspnoea 
will decrease, expectoration increase and be thick and glairy, 
the temperature fall, the pulse-beats decrease, and resolution 
occur. On the other hand, if not soon relieved, dyspnoea in- 
creases, the anxiety grows more intense, the perspiration more 
clammy, and the cyanotic stage precedes suffocation or coma. 
The patient succumbs either as the result of blood deterioration 
or asphyxia. 

A finger passed into the throat, in the absence of a throat- 
mirror, may detect an infiltration of the mucous lining and swell- 
ing and bogginess of the epiglottis. These parts, however, are 
often unaffected. In no case should the finger be used if the 
mirror can be employed, as the former serves to temporarily 



Jfc&y? 



Fig. 112.— Acute (Submucous) Laryngitis. 

increase the difficulty of respiration, and is always very annoying 
to the patient, The laryngoscopic mirror will disclose the 
exact condition. In the early stage the entire interior of the 
larynx will be found evenly congested, some of the parts swelled 
and cedematous, and the vocal bands pink or even deep-red. 
If the condition be well advanced, the swelling and oedema may 
be so great as to mask the normal shape of the parts, or the 
ventricular bands so enlarged as to obscure the vocal bands. 
The epiglottis may resemble a turban, in shape, and the aryte- 
noid cartilages be so infiltrated as to look like two bags of fluid ; 
they are not pale, however, as in oedema. In the severer cases 
the glottic opening will be reduced to a mere slit, or even oblit- 
erated. Milder cases present a modified picture of the preceding. 



ACUTE (SUBMUCOUS) LARYNGITIS. 



393 



Diagnosis. — The diagnosis can only be made with certainty 
by the aid of the laryngeal mirror ; hence, in very young chil- 
dren it may be impossible to distinguish the affection. It may 
be differentiated from membranous laryngitis by the absence of 
a pseudomembrane, and from acute oedema of the larynx by the 
presence of acute inflammation of that organ. The history will 
serve to separate acute laryngitis from spasm, abscess, or neoplasm. 

Prognosis. — The prognosis is grave, unless promptly and 
judiciously treated. Fortunately, the disease is rare, as it some- 
times proves fatal in less than twenty-four hours. 

Treatment. — The treatment must be prompt and decisive. 
The patient is . to be kept in bed, and attempts at speaking 



Fig. 113.— Mackenzie's Laryngeal Bistoury. 



prohibited ; the temperature of the room should be from 70° to 
75° F. ; air should be admitted, but no draughts allowed to 
blow over the bed, and the atmosphere kept constantly moistened 
with steam or an atomized fluid (see " Diphtheria of the Pharynx 
and Larynx"). Locally, some means should be employed that 
will serve to reduce the infiltration. For this purpose tannic 
acid may be used as an inhalation of tannin-impregnated steam ; 
but menthol, eucalyptus globulus, or lime-water may be used in 
the same way, and to better advantage. Where deglutition is 
very painful and difficult a 4-per-cent cocaine or menthol spray 
is often advisable, and if applied directly to the infiltrated tissue 
will reduce it temporarily. The external application of hot 
poultices or hot flannels may alleviate suffering. When the 



394 DISEASES OF THE NOSE AND THROAT. 

preceding measures fail to give prompt relief to the respiratory 
difficulty, the physician should resort at once to scarification, 
intubation, or tracheotomy. As scarification is attended by the 
least after-care, it may be tried first. For this purpose a guarded 
laryngeal bistoury is carried, by the aid of a laryngoscope, 
directly to the affected area, and plunged into the overlying 
membrane. In its absence, a curved knife-blade should be 
wrapped with string or plaster to within a short distance of its 
point, so that the cutting edge cannot harm the base of the 
tongue. If a laryngeal mirror be wanting, the index finger, 
acting as a guide, is to be carefully passed to the cedematous 
region, if it can be reached. If there be no other means at 
hand, the sharpened and pointed finger-nail may be used. It is 
not sufficient that the membrane be pierced ; a rather free open- 
ing should be made, that the accumulated contents can find a 
ready exit. Should the foregoing fail to give relief, intubation 
or tracheotomy must follow. 

Many operators still prefer tracheotomy to intubation, and 
the former is sometimes required where the latter fails, or for 
some reason cannot be accomplished (see " Diphtheria of the 
Pharynx and Larynx"). Although tracheotomy, like intuba- 
tion, is not always successful, it nearly always gives the desired 
relief to the dyspnoea, which permits the application of remedies 
under greatly improved conditions. The tracheal opening should 
be low, that the cannula may reach below the infiltration. 

After the patient is convalescent, great care should be ex- 
ercised that a relapse does not occur from draughts or early ex- 
posure to damp or night air. A chronic larygitis may result or 
the condition prove a stepping-stone to a tubercular affection. 
The prophylactic treatment depends much upon the habits of 
the individual ; if he be too sedentary or too careful of exposure, 
this should be gradually regulated and he should be systemati- 
cally accustomed to endure greater atmospheric changes. Too 
great exposure and voice abuse should be corrected. 



CHRONIC CATARRHAL LARYNGITIS. 395 

Therapeutics. 

Apis. — Especially if there be constriction of the pharynx 
with oedema of the uvula and half-arches, giving rise to the 
sensation of a foreign body. Hoarseness or aphonia ; difficult 
or almost impossible breathing; or feeling of suffocation. 

Crotalus. — Acute laryngitis from scalds, stings of insects, etc. 

Fer. phos. — The laryngeal lining is red, cedematous, and 
painful, almost from the beginning of the attack. 

Sang. can. — Aphonia, with a sensation of swelling or even 
of suffocation. Dry, burning in the throat. 

Compare " Subacute Laryngitis " and " (Edema of the 
Larynx." 

CHRONIC CATARRHAL LARYNGITIS. 

Etiology. — Post-nasal catarrh is the chief factor in the pro- 
duction of chronic laryngitis, the inflammatory condition extend- 
ing to the vocal organ either by continuity of tissue or as a 
result of the entrance of the discharges from the naso-pharynx. 
The next most important cause lies in the improper use of the 
voice in speaking or singing ; follicular pharyngitis established, 
the larynx is soon invaded by the catarrhal process. Too free 
use of the voice during convalescence from acute or subacute 
laryngitis or measles, use of the voice when in poor health, dur- 
ing menstruation, in boys during the " change of voice," and 
overuse in public speaking are sometimes responsible for the 
affection. Further causes are : incomplete recovery from acute 
or subacute catarrh, a depressed or weakened general system, 
muffling the neck, speaking or singing in the cold or damp air 
(especially after the use of the voice in-doors), drinking cold water 
during or after voice use, inhaling irritating chemicals, dust, 
fumes, filings, grindings, repeatedly clearing the throat, and re- 
laxed uvula ; but, most important, habitual mouth-breathing. 
The gouty and rheumatic diatheses and interference with the 
portal circulation are possible excitants. 

I dare not pass this part of the subject without referring to 



396 DISEASES OF THE NOSE AND THROAT. 

the pernicious habits of tobacco-smoking and alcoholic im- 
bibition. With tobacco, it is not always the one using it who 
alone suffers, for sometimes those confined in an atmosphere 
vitiated by its fumes sustain the most harm. The influence 
of alcohol upon the voice has been noted under '-Alcoholic 
Laryngitis." 

Pathology. — Pathologically there is often an hypertrophy 
of the mucous membrane, with increased and perverted secre- 
tion ; when this hypertrophy is considerable, and implicates the 
ventricular bands, these structures may completely hide the en- 
trances to the ventricles of Morgagni, or even overhang, rest 
upon, or hide the vocal ligaments. The ventricular outlets are 
often slightly purplish, indicating a catarrhal condition. In the 
inter-arytenoid region the mucous membrane is often so thick- 
ened as to be thrown into vertical folds, as the vocal processes 
are rotated toward the median line. In some cases the glands 
are so implicated as to give rise to follicular laryngitis, some- 
what similar to the condition found in the pharynx. Such a 
state is often accorded the special title: " follicular," or "gland- 
ular," laryngitis. This may lead to a tuberculosis of the organ. 

Abrasions of the mucous membrane (erosions) sometimes 
occur upon the vocal bands and inter-arytenoid surface, but true 
catarrhal ulcers are not found. As a result of the general 
catarrhal process or of the erosions, polypi and papillomata 
may occur. The presence of abrasions, glandular enlarge- 
ments, and swellings is sufficient to cause a careful thoracic 
examination. Vicarious haemorrhages sometimes result in preg- 
nant women, or shortly after confinement, and in those who 
menstruate vicariously. As a rule, it will be noticed that the 
mucous membrane is thickened, congested, and undergoes other 
catarrhal changes, as a result of the various causes enumerated, 
until the condition becomes a chronic pathological alteration in 
the tissues. 

Symptoms. — Hoarseness is not constant in the milder 
cases, the voice being frequently good during summer and 



CHRONIC CATARRHAL LARYNGITIS. 397 

winter ; but the symptom usually returns with the changeable 
spring and autumn weather. In the worst cases there may be 
constant hoarseness or even aphonia, the vocal defect often 
being exaggerated in the morning directly after rising and in 
the evening after dusk. Although frequently hoarse, when begin- 
ning to speak, the voice, after a short time, may become clear, 
to again deteriorate from dislodgment of mucus, muscular 
fatigue, spasm, or congestion due to faulty vocalization. Fatigue, 
either mental or physical, may increase the hoarseness ; but 
eating often temporarily improves speech. The singing voice 
may be husky, hoarse, or lost, depending upon the condition 
present ; the tones are often temporarily stopped by the partial 
dislodgment of pieces of mucus, which drop between the bands, 
preventing their close coaptation. 

Expectoration is usually slight, but occasionally quite pro- 
fuse. It may be thin or thick, lumpy or ropy, and easily dis- 
lodged or tenacious ; in the latter instance it is attended with 
much coughing and clearing, — two pernicious habits, as they 
lead to an increase in the congestion. The color of the discharge 
may be white, yellow, green, brown, or a gradation of these; 
but it is rarely bloody. When strings or bands of mucus are 
found stretching across the open glottis from one band to the 
other, a diagnosis of chronic laryngitis may be made without 
further search. 

Sometimes the secretions dry very rapidly and become dis- 
colored, thus constituting a true laryngitis sicca. The crusts 
usually form about the rima glottidis and cause aphonia, cough, 
sensation of a foreign body, and occasionally difficult respiration. 
On the other hand, the chief symptom may consist of a profuse 
discharge (laryngorrhcea), especially marked during vocalization. 
Acute pain is not complained of in chronic laryngitis, but there 
is usually a dryness, burning, or tickling in the larynx, and a 
sense of fullness or constriction in the laryngeal region. Systemic 
disturbance or difficulty of respiration is rare in uncomplicated 
cases, though associated nasal and bronchial asthma are not 



398 DISEASES OF THE NOSE AND THROAT. 

infrequent. Cough is usually simply sufficient to dislodge the 
mucus, unless the trachea or deeper parts be also involved. 
Difficulty is occasionally found in the production of certain 
tones, as a rule the higher notes of the compass ; this is usually 
due to a slight catarrhal change, but occasionally, no doubt, to 
faulty methods of voice production, with their resultant muscular 
strain and fatigue. 

The laryngoscopic appearances are quite characteristic. 
While the entire laryngeal lining may be congested, only small 
areas, as a rule, are so altered ; thus, one or both bands or 
portions thereof may be slightly reddened. These ligaments 
are occasionally uniformly discolored, a dirty or ashy hue obtain- 
ing. The capillary vessels of the epiglottis are sometimes 
slightly dilated and the cartilaginous mucous covering thick- 
ened, especially as the result of alcoholic abuse. The folding 
of the inter-arytenoid mucous membrane may prevent the com- 
plete coaptation of the posterior ends of the bands, which, added 
to their congestion and the presence of mucus, may give rise to 
the altered voice. In many cases, however, there probably is 
also a slight rheumatism of the vocal muscles. 

Prognosis.— It is safe to say that in uncomplicated cases 
there is no danger to life, but chronic laryngeal catarrh may 
lead to phthisis or extend to the deeper parts, just as a post- 
nasal catarrh may lead to laryngeal complications. A chronic 
catarrh of the larynx, furthermore, is very difficult to cure, but, 
if the exciting cause be removed before great mischief has been 
done, a majority of the cases will recover ; if, on the other hand, 
there be much thickening of the mucosa, the cure is doubtful, 
or, if accomplished, the next catarrhal attack may cause a 

relapse. 

Treatment, — In the treatment of every case two points are 
to be carefully questioned, namely : 1. Is there a nasal catarrh 1 ? 
2. Is there a false method of vocalizing] If the cause be 
nasal catarrh, no attempt need be made to correct the laryngeal 
trouble without, at the same time, treating the nose ; otherwise 



CHRONIC CATARRHAL LARYNGITIS. 399 

failure will generally result. If false vocalizing methods be the 
cause, the physician should be aided in his work by a competent 
vocal teacher. The following rules, if put into practice, will 
generally result in decided relief: 1. Sing or speak as little as 
possible when hoarse. 2. Always pitch the voice low in con- 
versation. 3. Always sing with as little exertion as possible. 
4. Never sing higher than the easy compass of the voice, as 
nothing will be gained and much harm may result. 5. Avoid 
straining the muscles of the pharynx in speaking or singing. 
6. Always breathe through the nose. 

Internal medication will often cure, but it is not always 
possible to attain this end speedily without the use of adjuvants; 
of these, oily sprays of eucalyptol, iodine, or hydrastin, each 5 
per cent, are efficient. Usually, it is not well to introduce 
aqueous solutions unless effectual and speedy cleansing be 
desired, as such fluids are apt to flood the larynx and set up 
reflex spasm, or to pass into the deeper parts and give rise 
to acute inflammation. It is often advisable to medicate 
glycerin or petroleum products with the lower preparations of 
the remedy used internally. Vapors and nebulas are of un- 
doubted utility ; but steam inhalations are of questionable 
value, as they may occasion extra irritation, relaxation, or even 
inflammation, especially if the inhalations be used very hot and 
the patient go into the open air soon afterward. 

Mild astringents (chloride of zinc, tannic acid, or gallic 
acid, each 5 grains to the ounce of glycerin) are indicated, espe- 
cially where the mucous membrane is sluggish ; these remedies 
may be used as sprays or on a cotton-covered laryngeal probe. 
In making the applications a small piece of absorbent cotton is 
carefnlly wound around the roughened end of a laryngeal probe 
and dipped into the solution ; any superabundant liquid should 
be squeezed out against the inside of the neck of the bottle. A 
laryngeal mirror is to be held in the left hand and, with the 
right, the medicated probe passed into the larynx, aided by the 
reflection in the laryngeal mirror. Care must be exercised not 



400 DISEASES OF THE NOSE AND THROAT. 

to touch the tongue, palate, fauces, or epiglottis, lest retching 
or spasm be excited. With the swab directly above the epi- 
glottis, ask the patient to sound a, and, when the cartilage is 
raised, quickly but gently elevate the hand, carry the cotton into 
the larynx, and draw it lightly along the bands before removing 
it. Some spasm will follow, but quickly subsides ; should it 
cause much annoyance, gently slap the patient, in the inter- 
scapular region, with the palm of the hand ; this is an exceed- 
ingly rare necessity, and one which will scarcely arise if care be 
exercised with the first application. The use of the laryngeal 
brush is not advisable, as it is less efficient than cotton- or 
sponge, and its hard frame is apt to bruise the delicate mem- 
brane. The oily sprays recommended in " Chronic Pharyngitis" 
are usually better than the preceding, unless it be desired to 



£.A. YARNALL. PHILA. 



Fig. 114.— Laryngeal Applicator to be Attached to a Universal 
Laryngoscopy Handle. 

remove mucus. If there be thickening of the laryngeal lining, 
iodine gr. x to glycerin 5j is best. If hoarseness remain after 
the inflammation has been overcome, electricity and vocal exer- 
cise will go far to restore the lost tone. 

The patient who suffers from chronic laryngitis is nearly 
always advised not to use the voice for singing, or even for loud 
speaking, and silence is often enjoined for weeks or months. 
This does not accord with my own experience, and, unless very 
severe hoarseness exist or the patient speak improperly, he 
should be requested to use moderate tones, and to sing gently 
and well within easy vocal compass ; in no instance is he to 
transgress this, which is often but about one octave in persons 
affected with chronic laryngitis. The patient should never 
attempt conversation in a noisy or dusty place, and nasal res- 
piration must be rigorously enforced. If there be a decided 



THERAPEUTICS OF CHRONIC CATARRHAL LARYNGITIS. 401 

hemorrhagic tendency, an acute exacerbation of the chronic 
affection, or if the use of the voice cause fatigue, rest is to be 
insisted upon. As a preventive measure, the morning, cold, 
salt-water bath to the neck and chest, if followed by brisk rub- 
bings, takes precedence on account of its invigorating influence, 
its aid to circulation, and its tendency to prevent " cold-catch- 
ing." All such pernicious habits as smoking, tippling, and 
loud talking and screaming in the open air are to be interdicted. 
Dusty or otherwise irritating occupations should be avoided if 
possible, else some form of respirator should be worn. 

For some persons a change of climate will be necessary. 
Care should be exercised that such a change be to a region 
which is rather dry and with few sudden fluctuations in the 
temperature. 

Therapeutics. 

Ammon. caust. — Catarrhal and paretic aphonia ; general 
muscular weakness ; burning, rawness in pharynx and larynx. 

Argent, met. — Expulsion of lumps of clear mucus resem- 
bling boiled starch. 

Argent, nit. — " Inflammation and swelling of the posterior 
wall and lining of the larynx, attended by a sensation of a clog 
in the vocal organ, with hoarseness or loss of voice, continual and 
vain efforts to swallow, with pain and soreness in deglutition, 
much hawking, considerable muco-purulent expectoration or titil- 
lation in the larynx, with dry, spasmodic cough." (Meyhoffer.) 

Ars. — Laryngeal lining dirty-red or ansemic, puffy ; with 
bluish-red patches ; burning in the larynx ; voice husky, tone- 
less ; fatigue from speaking ; abrasion or superficial ulceration 
of follicular origin ; follicles enlarged and exude a gray mucus. 

Calc. carb. — Very weak voice ; dilated veins on the soft 
palate and pharynx, giving rise to a bluish tinge. Cold hands 
and feet. Raw feeling in the larynx, with thick, jelly-like, or 
tough discharge from the larynx and naso-pharynx. 

Carbo veg. — Chronic laryngitis of elderly persons or those 
who are poorly nourished. " This drug is principally indicated 



402 DISEASES OF THE NOSE AND THROAT. 

by a considerable hoarseness with dryness of the larynx, without 
pain ; this increases, at night, to aphonia. This loss of voice, 
without remission, is comparable with that produced by paralysis 
of the vocal bands, and is a sure indication for the remedy. 
Talking is not accompanied by pain in the larynx, but cough, 
when present, occasions burning pain." (P. Jousset.) Lining 
of the larynx, especially of the ventricular bands, ashy, purplish ; 
vocal bands appear thick. Hoarseness or aphonia ; moderate, 
easy, lumpy expectoration. Venous capillary dilatation of the 
pharynx and larynx. " Considerable swelling of the vocal lig- 
aments; the lining of the larynx, and particularly of the ven- 
tricular bands, of a dingy, purplish tint." (MeyhofFer.) In- 
durated and tender glands. The condition is often caused by 
a warm, moist atmosphere. 

Caust. — Great fatigue from talking ; voice reduced to a 
whisper ; larynx feels tired and sore ; cough produces pain. 
AVhen attempting to sound a high tone, the voice gives out or 
ends in a squeak. Lack of co-ordination (co-operation) of the 
vocal bands ; a frequent symptom after the subsidence of acute 
or subacute catarrh. Hoarseness of singers, worse in the morn- 
ings, and in dry, cold weather. Mucous lining anaemic ; vocal 
bands gray or dingy in appearance, and are seen to come in 
contact, but separate before a tone is produced, the muscles 
being so weak that the expiratory current forces the ligaments 
asunder. Here causticum is the true " toner-up." For paretic 
hoarseness or a hoarseness without visible laryngeal change no 
remedy is comparable to caust., 12 x to 30 x. Dr. W. W. Van 
Baun says (Hahnemannian Monthly, February, 1891): "There 
are rawness and soreness down the throat and trachea, with an 
unsatisfactory cough. Loud and painful as it may be, it is not 
sufficient to bring up the phlegm that is apparently lodged 
somewhere in the respiratory tract." 

Hepar. — Especially when the catarrh is aggravated by 
overuse or strain of the vocal apparatus ; difficult expulsion of 
scanty, tenacious, muco-purulent secretion ; larynx sore and 



THERAPEUTICS OF CHRONIC CATARRHAL LARYNGITIS. 403 

painful during cough or speech ; hoarseness or aphonia ; larynx 
feels dry and is sensitive to cold air. Follicular pharyngitis and 
laryngitis ; laryngeal catarrh grafted on a tuberculous constitu- 
tion. " This remedy," says Dr. J. S. Mitchell ( Arndt's " System 
of Med."), " has done so much for me that I consider it the most 
effective of all remedies. Its use in cases occurring in profes- 
sional singers has been attended with such success that I do not 
hesitate, on taking the case, to express the belief that not only 
the laryngeal inflammation will be relieved, but that a manifest 
improvement will be apparent in the quality of the voice." 

Iodine. — Hoarseness, soreness, constriction, aching in the 
larynx ; one spot is painful to pressure, with spasmodic cough 5 
followed by the expulsion of scanty, sticky, lumpy mucus ; fol- 
licular enlargements; perhaps ulceration. Constriction about 
the larynx and trachea. One of the strong indications for the 
drug is that, although the patient eats heartily, he grows thinner- 
Kali bi. — Varicose veins in larynx ; vocal bands and post- 
laryngeal wall puffy; larynx feels dry; voice rough and hollow; 
scanty, stringy expectoration, which can sometimes be seen 
stretching across the glottis from band to band. I have rarely 
seen failure from kali bi. when this last (clinical) symptom was 
present. In addition to the 12 x internally, I usually employ a 
3-per-cent spray of the crude remedy. The late Dr. Jno. Mey- 
hoffer, of Nice (" Chronic Diseases of the Organs of Respira- 
tion," vol. i), gave the following : " The ary-epiglottic liga- 
ments, the ventricular bands, and lining of the posterior part of 
the larynx dark-red, puffy, and partly covered with a grayish 
mucus ; the vocal cords slightly injected, and some varicose 
veins in the pharynx." 

Kali iod. — " It gives good results in pain, contraction, and 
heat in the larynx ; in morning, hoarseness ; intolerable tickling 
in the larynx, with dry, teasing cough, etc. It has a special re- 
lation to cases depending on syphilis, scrofula, and rheumatism." 
(Dr. George Moore.) The arytenoids are purplish. Follicular 
ulceration ; voice hoarse and inaudible above the middle of the 
compass. 



404 DISEASES OF THE NOSE AND THROAT. 

Manganese is very efficacious "in laryngeal catarrh, in 
weak, anaemic individuals, or in such as exhibit tubercular de- 
posits in the lungs, with voice hoarse in the morning, but becom- 
ing gradually clear after the expulsion of lumps of consistent 
mucus ; moderate, partial injection of the ventricular bands and 
venous dilatation in the throat and pharynx. We use the first 
and second potencies." (MeyhofFer.) 

Merc. sol. — Hoarseness in strumous or hereditarily syphi- 
litic patients ; mucous lining swelled and livid in color (mere, 
iod.). 

Phos. — Larynx feels sore and dry ; inspired air gives to the 
parts a sensation of rawness ; cough hoarse ; expectoration 
scanty ; hoarseness or aphonia worse in the evening ; voice tires 
easily. The vocal bands are usually highly injected or a dirty 
yellow ; abrasions are occasional complications ; the arytenoid 
and inter-arytenoid and soft tissues dark-red and swelled or 
thickened. 

Selen. — Hoarseness from long speaking or singing; fre- 
quently clears the throat on account of colorless, starchy mucus. 
Chronic follicular enlargements, both in the pharynx and larynx, 
especially in tuberculous patients, or even in the early stage of 
laryngeal phthisis. 

Sulph. — As recommended by Hahnemann, when chronic 
laryngitis follows suppression of superficial eruptions. The 
symptoms calling for this remedy are: voice hoarse , rough, deep, 
or aphonic ; worse in the morning ; talking fatigues. After 
failure of caust. 

Congestion of the laryngeal lining, either as a cause or a 
result of hysterical (?) clonic spasm of some of the vocal muscles, 
is met by hepar, ignatia, kali brom., lach., phos., and sepia. 
(Compare " Remedies for the Vocal Defects of Singers.") 



CHAPTER XXX. 

Hypertrophy, Atrophy, (Edema. 



SUBGLOTTIC CHRONIC LARYNGITIS. 

This is an exceedingly rare form of laryngitis, especially in 
this country. It is a localized inflammation and hyperplasia, 
catarrhal in origin. It appears as a dull, pink, or dusky swell- 
ing of the under surface of the vocal bands, apparently a pro- 
jection of the vocal (internal thyro-arytenoid) muscle. Gerhardt 
named it "chorditis inferior hypertrophica." It gives rise to 
hoarseness or aphonia, and may even cause severe dyspnoea, re- 
quiring intubation or tracheotomy. If a tube be inserted, it 
should be left in position until irritation necessitates its removal ; 
the constant pressure exerted usually serves to reduce the hyper- 
plasia. The repeated introduction of the tube may be necessi- 
tated. If tracheotomy be performed, the case is to be treated 
mechanically, as recommended under " Stenosis of the Larynx." 
The remedies indicated are ferrum iod., iodine, kali mur., and 
spongia. 

CHRONIC HYPERTROPHY OF THE LARYNX CHRONIC SUBMUCOUS 

LARYNGITIS. 

Etiology. — Although a rather frequent form of laryngitis 
in Europe, this country furnishes few examples. Chronic catar- 
rhal laryngitis is its most frequent cause ; acute affections rarely 
induce it, and it is sometimes the result of laryngeal perichon- 
dritis. Typhoid fever is the only one of the more general acute 
conditions giving rise to it. Syphilis, scrofula, and phthisis may 
produce it. Alcoholic beverages and gont are active causes of 
hypertrophy of the epiglottis. As a rule, the subglottic portion 
of the larynx participates to the greatest degree, and often solely, 
although other portions may be hypertrophied. The new struc- 
ture often becomes so hard that it is difficult to cut it with a knife. 

(405) 



406 DISEASES OF THE NOSE AND THROAT. 

Symptoms. — If the epiglottis alone be thickened, the sen- 
sation is that of a foreign body, with dragging in the pharynx 
as though the base of the tongue were too heavy. If there be 
a general hyperplasia of the mucous and submucous tissues, 
hoarseness, aphonia, or dyspnoea will exist, according to the 
degree and situation of the thickening. 

The vocal bands are frequently hypertrophied and their 
edges rounded. The ventricular bands may be so enlarged as to 
obstruct the openings to the laryngeal sinuses, overhang and 
rest upon the vocal bands ; thus hiding the latter and preventing 
their vibration. When the epiglottis is involved, it is thick, 
sluggish in action, and often projects over the laryngeal opening. 

The lining of the larynx is deep-red, often with an appear- 
ance of tension of the dry and glazed mucous membrane ; the 
vocal bands occasionally present a very deceptive appearance, due 
to the longitudinal, irregular thickening, so that they seem to 
be split along their edges as though there were two in close con- 
tact, one above the other. The position of the vocal bands, 
when immobile from muscular involvement or mechanical hin- 
drance, is in the median line, thus interfering with respiration 
and augmenting the already noisy, stridulous breathing. 

So-called chorditis tuberosa might be considered with this 
affection, as they are often associated, although I have preferred 
to class it among tumors. 

Prognosis. — The prognosis of the general disease is grave 
if the hypertrophy be at all marked, for, even though the 
amount of permanent dyspnoea be moderate, the accumulation 
of mucus during sleep may be sufficient, when added to the 
subsequent spasm, to produce death in a few moments. Accord- 
ing to Schrotter, spontaneous resolution may take place. It is 
possible, as a rule, to reduce a moderate hypertrophy of the 
hypoglottic portions of the larynx. 

Treatment. — The galvano-cautery may be used very 
cautiously for the graver conditions, but the vocal bands and 
muscles must be avoided. If dyspnoea be increasingly severe, 



ATROPHY OF THE LARYNX. 407 

intubation had better be performed, but Schlatter's hard-rubber 
tubes may be employed (see " Stenosis of the Larynx"). If 
the condition grow worse in defiance of this treatment, the 
trachea should be opened and the larynx subsequently dilated. 
The remedies best suited to the condition are argent, nit., 
fer. iod., iodine, kali iod., mere. iod. ruber, nitrate of sang., 
rhus tox., and thuja. If the change be of syphilitic origin, the 
various forms of iodine are to be preferred ; if of rheumatic 
origin, rhus will do the most good ; while, if scrofula compli- 
cate the condition, calc. carb., calc. fluor., and iodine must 
receive attention. Lastly, if there be associated hypertrophy 
of the pharyngeal and laryngeal follicles, fer. iod. and nitrate 
of sang, should be considered. 

ATROPHY OF THE VOCAL BANDS. 

Of this degeneration little has been written, and I have 
seen but two well-marked cases : one, that of a patient in Prof. 
Schnitzler's clinic, in Vienna ; the other, a private patient. A 
number of cases of apparent thinning or narrowing of the bands 
have come under my notice, but I have not deemed them suffi- 
ciently characteristic to be called typical. One case personally 
communicated by Dr. W. R. King was practically cured by fara- 
dism, both externally and internally ; during the application of 
the former the patient made use of " slight vocal exercise." A 
cleansing spray was used, followed by the local application of 
the ammoniated tincture of guaiac. of the strength of 3j to Sj of 
water. Canst. 6 x and gels. 3 x were the only internal remedies 
used. 

ATROPHY OF THE LARYNX. 

This condition is, perhaps, always associated with atrophy 
of the nose and pharynx, in which ozaena of the nose and trachea 
plays the leading causative role, on which account I have pre- 
ferred to consider it with " Tracheal Ozsena." Its treatment is 
practically that of the latter disease. Dr. Malcolm Leal writes: 
" Psorinum has certainly proved beneficial in one case of atrophic 
laryngitis with formation of crusts." 



408 DISEASES OF THE NOSE AND THROAT. 

ACUTE (EDEMA OF THE LARYNX (CEDEMA GLOTTIDIS). 

Etiology. — This is often an indication of some profound 
systemic change, notably scarlet, typhoid, and typhus fevers ; 
small-pox, phthisis, syphilis ; cardiac, hepatic, pulmonary, and 
renal affections ; erysipelas, and pyaemia. Pressure upon the 
laryngeal, thyroid, facial, internal jugular, or innominate veins, 
and pharyngitis, or retro-pharyngeal abscess, may cause cedema- 
tous laryngitis. Acute pharyngitis and malignant tumors of 
that cavity may, by continuity, induce laryngeal dropsy. Trau- 
matic causes are : foreign bodies, suicidal attempts, inhalations 
of scalding steam, contact of scalding water, some form of 
chemicals, and operations upon the throat. Strubing describes 
an angeiomatic oedema which reaches its acme in three hours, 
and which may result from cold or be without traceable cause. 

Acute laryngeal dropsy occurs most frequently in middle 
life, less frequently in early youth, and least in advanced years. 
Should it occur later in life it is usually the result of cardiac, 
renal, or circulatory disturbances. 

Pathology. — It is a transudation or infiltration into the 
submucous tissue of a serous, sero-purulent, or rarely a san- 
guineous fluid. This accumulates in those portions of the larynx 
in which the tissues are least closely adherent to the cartilagi- 
nous frame- work ; thus the ary-epiglottic folds, ventricular 
bands, and arytenoid mucous membrane suffer most frequently. 
As the infiltration increases, the tissues stretch, become pale, 
waxy, and translucent, with apparent tissue tension ; after death 
the parts are shrunken and wrinkled. The microscope gener- 
ally reveals the presence of leucocytes in the connective-tissue 
meshes of the submucous structures. 

Symptoms. — In mild cases these are generally of little 
moment ; they usually consist of a sensation of fullness in the 
laryngeal region, with slight dry cough. In some fatal cases, 
a sudden paroxysm of dyspnoea is the first indication of a laryn- 
geal alteration ; the voice may be impaired, even to aphonia, 



ACUTE (EDEMA OF THE LARYNX. 409 

the result of mechanical interference. The laryngoscopic appear- 
ances are characteristic : the swelling is smooth, pale, and 
waxen; the glottis is usually encroached upon to a high 
degree ; and the ary-epiglottic folds are often so infiltrated as 
to meet in the median line. The ventricular bands may be 
sufficiently swelled to completely close the vestibule and the 
swelled epiglottis completely hide the larynx. If complicated 
by other laryngeal alterations it presents the oedema in addition 
to the original defect, in which case the dropsy is not of that 
peculiar waxen color, and is thus often overlooked or considered 
a product of inflammation. 

In the severer forms respiratory difficulty is very great and 
death may occur in a few hours, unless prompt relief be afforded. 
At first the symptoms are not unlike those of the milder forms ; 
later, however, labored breathing appears and may increase so 
rapidly as to soon produce severe dyspnoea. The patient makes 
frantic, but only partially successful, efforts to inhale, owing to 
encroachment of the infiltration upon the glottic space. At first 
inspiration alone may be affected, but later expiration suffers as 
well. The temperature rises, the voice is lost, cough is croupous 
and incomplete, deglutition painful or difficult ; the patient 
breaks out in a profuse, cold perspiration, his head is thrown 
back, he grasps at the throat, and, in his efforts to gain a little 
air, tears off any clothing that may be about it. These symp- 
toms are not constant at first ; there are short periods of respite, 
during which the sufferer is able to inspire more freely ; but 
never with ease, unless the condition subside, in which event 
the breathing becomes freer and the pulse and temperature de- 
cline. Expectoration, which up to this stage is almost wanting, 
appears, and the patient gradually falls into a peaceful and re- 
freshing sleep, from which he arouses greatly improved. If the 
attack prove fatal, the symptoms increase in severity, the tem- 
perature falls below normal, the patient becomes cyanotic, the 
pulse fails, the respirations become feebler from minute to 
minute, unconsciousness supervenes, and the patient dies from 



410 DISEASES OF THE NOSE AND THROAT. 

apncea after a most terrible struggle for existence. The disap- 
pearance of the oedema and the subsidence of the dyspnoea do 
not always denote recovery, however, as death may occur even 
then, either from the primary disease or prolonged deoxidation 
of the blood. Fortunately, acute dropsy of the larynx is rare. 

In infra-glottic oedema, the upper portion of the larynx may 
escape, but generally, in such cases, the infiltration begins above 
and passes downward. The chief symptom is dyspnoea. The 
laryngoscope reveals a marked whitish infiltration below the 
vocal bands ; the latter are often sluggish in action, owing to 
pressure upon the vocal muscles, which are, also, sometimes 
infiltrated. 

Prognosis. — In the supra-glottic disease the outlook is gen- 
erally favorable if the condition be promptly recognized and 
properly treated ; but in the subglottic form the prognosis is 
nearly always unfavorable, even though means for relief be 
promptly applied, as the whole length of the trachea may be 
infiltrated. Primary acute oedema of the larynx is less favor- 
able than the secondary form, but the latter is apt to become 
chronic. The duration of the active stage is rarely more than 
from three to four days, but complete recovery may be delayed 
some weeks. Relapses may occur or complications arise and 
bring on a suddenly fatal issue, even after recovery seems as- 
sured. Death results either from slow carbonic-acid poisoning 
or stenosis, often aided by laryngeal spasm. Complications are: 
severe inflammation, suppuration, perichondritis, paralysis, and 
membranous laryngitis. 

Diagnosis. — The diagnosis can sometimes be made with 
the finger passed gently into the laryngeal region, though this 
is not to be recommended, as it is apt to increase the dyspnoea. 
The distinction between this affection and a deeply situated 
retro-pharyngeal abscess may be made — in the absence of the 
laryngoscope — by gently raising the larynx by external manipu- 
lation ; if oedema exist, respiration will not be relieved as in 
case of abscess. 






ACUTE (EDEMA OF THE LARYNX. 411 

Treatment. — As the condition may so rapidly prove fatal, 
it is necessary that treatment be prompt and decisive. The pa- 
tient should remain in one room, the temperature of which 
should be above 70° F., and the air kept humid as recommended 
in membranous laryngitis. At the outset there are no better 
remedies than apis, ars., kali iod., and sang. can. : with these 
many cases have been aborted or saved the necessity of 
mechanical procedure. 

If, after a few hours, it be found advisable to use local 
measures, the inhalation of steam, plain or impregnated with 
tannic acid or alum, will act both gratefully and beneficially. 
It is best inhaled from the spout of a croup- or tea- kettle, care 
being exercised that the steam do not scald. A short paper 
cone or rubber tube may pass from the spout of the kettle to 
the mouth. Inhalations should be continued for a few minutes 
only; otherwise they are apt to prove exhausting. A 4-per- 
cent solution of cocaine, carefully sprayed upon the cedematous 
tissue, will generally give temporary relief and perhaps obviate 
an operation ; and the same is often true of menthol (4-per- 
cent) in albolene. 

Powders should not be used if there be much dyspnoea ; 
but an insufflation of alum or tannin in the early part of the 
attack often acts with effect. Medicines should not be applied 
with the brush or cotton-carrier even in the early stage, lest 
they induce fatal spasm. A few drops of oil of mustard rubbed 
over the larynx, externally, have sometimes afforded relief. 
Mendoza {La Semaine Med., May 6, 1891) reports the cure of 
a desperate case by the subcutaneous administration of pilocar- 
pine; one-third of a grain in three divided doses in the course 
of twenty minutes. 

If the dyspnoea increase after a fair trial of the means sug- 
gested, some mechanical measure should be employed at once. 
First in the list of these stands scarification. In an emerg- 
ency a penknife-blade may be closed to a right angle with the 
handle and passed over the tongue to the cedematous tissue 



412 DISEASES OF THE NOSE AND THROAT. 

(see " Acute Laryngitis "). Usually, as soon as the sac has been 
ruptured the contents flow out, giving prompt and delightful 
relief, but such a result cannot be secured when the infiltration 
is very glutinous. Again, even though relieved, the oedema may 
recur and require a second evacuation. If scarification fail, an 
intubation tube should be inserted. The relief which follows 
is usually prompt and entirely satisfactory ; the dyspnoea at once 
ceases. After subsidence of the slight cough occasioned by the 
introduction of the instrument, the patient falls into a quiet 
sleep. The tube can usually be removed after one or two days, 
but must be re-inserted should dyspnoea recur. 

In the absence of O'Dwyer's apparatus, or, according to 
many, in preference to it, a bronchotomy should be performed — 
preferably a low tracheotomy, lest there be subglottic oedema, 
which may extend below the end of a tube placed high in the 
trachea. If an abscess occur, it should be opened as suggested 
under the head of " xlbscess of the Larynx." 

Following relief of oedema of the larynx, the posterior crico- 
arytenoid muscles may be paralyzed, necessitating tracheotomy. 

Therapeutics. 

Apis. — When the oedema occurs suddenly as a complica- 
tion or a sequence of burns or an acute disease, — for example, 
erysipelas and the eruptive fevers. 

Ars. alb. — When there is a predisposition to anasarca, due 
to chronic diseases or to a broken-down constitution ; and espe- 
cially when the laryngeal dropsy is the result of cardiac, aortic, 
or renal trouble. Burning in the larynx, worse from deglutition. 

Arum tri. — If due to diphtheria or scarlet fever. 

Bell. — " Sudden attack ; fauces deep-purple ; all the parts 
of the larynx cedematously swollen, pain deep in the throat ; 
stiff neck ; wild expression of eye ; great prostration. One drop 
of tincture in pint of water, by teaspoonful." (P. J. Valentine.) 

Chin. ars. — (Edema of the larynx, especially if the result 
of continuity. 



CHRONIC (EDEMA OF THE LARYNX. 413 

Crotalus. — From scalds, irritating vapors, stings of insects, 
etc. 

Digitalis. — (Edema of the larynx when occasioned by dis- 
orders of the heart or liver. 

Kali iod. — I have seen oedema occur during the use of the 
crude iodide of potassium, and have repeatedly seen syphilitic 
cedema disappear during its administration. 

Lach. — In connection with albuminuria; dark, almost 
black, urine, like coffee-grounds. 

Sang. can. — When secondary to acute pharyngitis, I know 
of no remedy to take its place. Dryness and burning in the 
pharynx and larynx, with expulsion of thick mucus. 

CHRONIC CEDEMA CHRONIC SEROUS INFILTRATION OF THE 

SUBMUCOUS TISSUE. 

Chronic cedema of the larynx is always secondary. It 
often follows the acute form, but it is usually secondary to peri- 
chondritis, phthisis, syphilis, malignant tumors of the larynx, 
or some systemic condition, as stated under the acute affection. 

Symptoms. — The symptoms are similar to those found in 
the acute variety, but the onset is gradual and dyspnoea never 
becomes threatening, unless an acute exacerbation occur. As 
it is often associated with some other laryngeal condition, it may 
be partially masked by the original affection. When secondary 
to a change in the kidneys, liver, heart, lungs, circulation, or 
brain the laryngoscopic appearances are characteristic and re- 
semble mild cases of uncomplicated acute oedema, but the mucous 
membrane over the swelling is even paler than in the acute variety. 

Prognosis. — The prognosis depends upon the primary dis- 
ease ; it is usually unfavorable except in syphilitic and perichon- 
drial cedema. 

Treatment. — i\ctive treatment is not required unless an 
exacerbation occur. (Edema of the epiglottis may so interfere 
with deglutition as to require scarification for its relief. This 
operation, however, is not as successful as in acute dropsy, 



414 DISEASES OF THE NOSE AND THROAT. 

because the effusion is less fluid. When below the vocal bands, 
intubation or tracheotomy may be called for as a last resort. 
After tracheotomy the patient is often obliged to wear the 
cannula for a long time. Since the adoption of intubation, 
bron chotomy is much less frequently required and the final 
results are more satisfactory. As a rule, treatment should be 
directed to the original condition, but apis and ars. find a wide- 
sphere of usefulness. 



CHAPTER XXXI. 

Abscess, Erysipelas, Lupus, Leprosy. 



ABSCESS OF THE LARYNX. 

Although usually a complication of another condition, 
abscess is sometimes the sole detectable expression of the patho- 
logical process. Its most frequent location is at the base of the 
epiglottis ; it occurs less frequently in the ary-epiglottic folds and 
ventricular bands, and very rarely in other portions of the 
larynx. 

Etiology. — Occasionally laryngeal abscess is apparently 
primary, but it is usually the result of some injury or acute 
affection of the larynx, or of a systemic malady. 

Symptoms. — The symptoms of laryngeal abscess are char- 
acteristic of pus formation generally, — malaise, chills, increased 
temperature, headache, etc., — in addition to the local and special 
symptoms. These consist of hoarseness ; pain of a lancinating 
character, worse on deglutition ; cough, dry and rasping ; stringy 
mucus ; and often dyspnoea. External manipulation may 
cause considerable pain or increased dyspnoea, aiid, if the pus 
lie outside the laryngeal cartilages, it may be detected by palpa- 
tion. The abscess may burst internally or externally. 

Prognosis. — This is usually good, but death may result 
from obstruction or flooding; necrosis or exfoliation of cartilage 
may follow, or an external sinus result. 

Treatment. — The abscess may require incision with the 
laryngeal bistoury ; if the purulent collection be extensive, a 
safety tracheotomy and tampon cannula may be necessary, in 
order to prevent suffocation from purulent flooding of the 
larynx and trachea. Subcutaneous abscess usually requires 
external dissection. 

The remedies are noted under " Abscess of the Nose" and 
" Retro-Pharyngeal Abscess." 

(415) 



416 DISEASES OF THE NOSE AND THROAT. 



ERYSIPELAS. 

Primary erysipelas of the larynx is of rather infrequent 
occurrence, it usually being an extension of the pharyngeal 
affection. The disease does not always invade the cutaneous 
surface and, like primary pharyngeal erysipelas, it may reach 
the surface later. The larynx is more or less congested in most 
severe cases of erysipelas of the head and face, but this is 
usually overlooked unless special search be instituted. 

Etiology. — According to Massei (" Ueber das Primare Ery- 
sipel des Kehlkopfes," Berlin, 1886) erysipelas of the larynx is 
a primary, sui generis disease. He further states that many 
cases which are considered phlegmonous laryngitis are, in fact, 
primary erysipelas. According to the same authority the dis- 
ease is an infectious one, caused by the presence of micro- 
organisms, namely, the streptococci of Fehleisen, and that lesion 
of the epithelium favors the entrance of these micro-organisms. 

Pathologically the same may be said here as under "Ery- 
sipelas of the Pharynx." 

Symptoms. — Even when primary there is usually a rise of 
temperature to 104° F. or more ; chilliness and malaise are gen- 
erally present. Usually, the first symptom that calls attention 
to the larynx is hoarseness or aphonia. The lymphatics of the 
laryngeal region are enlarged and the larynx is sensitive to 
touch ; difficult respiration may develop early, the result of 
oedema, which may extend to the trachea and bronchial tubes, 
or even result in congestion or oedema of the lungs. According 
to Peter Ryland (" Diseases of the Larynx ") it may lead to 
"galloping consumption." Difficulty in swallowing is almost 
always present, and may become so severe as to prevent deglu- 
tition, in which case it will be found necessary to resort to 
artificial feeding. 

Laryngoscopically, the appearance may be one of general 
congestion similar to that found in mild acute laryngitis ; more 
frequently oedema complicates the condition and gives the ap- 



ERYSIPELAS OF THE LARYNX. 417 

pearance of the severer form of the acute affection ; bullae are 
often present. The differentiation, however, is not always easy, 
although it is to be noted that with the oedema of erysipelas the 
infiltration is wandering and changes place, which is not true of 
either acute oedema of the larynx or of acute cedematous laryn- 
gitis. Massei considers this migratory character pathognomonic 
of erysipelas. 

Although it can usually be differentiated from laryngeal 
oedema by the appearance and by the disturbance of circulation 
(heart, kidneys, or lungs) in oedema, yet it does not always 
follow that the disease where these complications are found is 
not erysipelas ; for, in one of my cases there was an erythem- 
atous and cedematous alteration of the pharynx, congestion 
of the larynx, and albuminuria, in which no surface redness 
manifested itself for seven days, when erysipelas of the scalp 
and face made its appearance. 

Prognosis. — The disease runs a very rapid course, and 
sometimes proves fatal in a few hours. Although always doubt- 
ful, the prognosis is less grave in those cases in which there is a 
simple congestion of the laryngeal mucous membrane, the force 
of the poison showing itself elsewhere. Where there is severe 
oedema prompt treatment is required, and even then death may 
follow. If sloughing result, the prognosis is still worse. Ery- 
sipelas attacking the larynx in very old persons is generally 
fatal. When recovery occurs it is by resolution, and when 
death results it is from suffocation, collapse, oedema, or conges- 
tion of the lungs. 

Treatment. — The management of the affection must be 
prompt and decisive. The patient may swallow ice, or have it 
placed over the laryngeal region. The treatment is similar to 
that of pharyngeal erysipelas (which see), in addition to which 
it will be necessary to guard against dyspnoea, as in acute laryn- 
gitis. Scarification, bronchotomy, or intubation may be de- 
manded, The latter is preferable, as it obviates a cut surface, 
thus avoiding new foci of infection. With intubation, how- 

27 



418 DISEASES OF THE NOSE AND THROAT. 

ever, swelling of the tissues may obstruct the upper opening of 
the tube, but this is less a danger than that which arises from 
implication of the tracheotomy wound ; for the same reason 
intubation would seem better than scarification. If, however, 
the homoeopathic remedy be early administered, it is less fre- 
quently necessary to resort to these operative procedures. The 
medicines best serving to control the pathological process are 
apis, bell., and rhus tox. Dr. de Keghel (27 Union Horn., April, 
1891) gives the following indications for tuberculinum : " In- 
flammatory swelling and ulceration of the larynx. Erysipelatous 
oedema of the glottis." 

LUPUS. 

Primary lupus of the larynx is infrequent; it is nearly 
always associated with external manifestations of the disease ; 
for that reason the diagnosis is generally easy. Although it may 
occur in either sex and at any age, it is most frequent in females 
under twenty years (Gottstein). The disease is now known to 
exist in from 10 to 12 per cent of all cases of the cutaneous 
affection, but the symptoms are often so mild as to be over- 
looked unless special effort be directed toward their discovery. 

Etiology. — Its causes are obscure in many cases ; it seems, 
however, to attack by preference strumous subjects ; less fre- 
quently the tuberculous ; and very rarely those who are directly 
syphilitic. True, it seems that there must be a suitable soil for 
its development ; and it is pretty well established that trauma 
often has an influence in its appearance. 

Pathology. — Its pathology is practically that of tubercu- 
losis, as in both diseases there are granular infiltrations, giant 
cells, and tubercle bacilli, although the latter are far less numer- 
ous in lupus than in phthisis. The disease starts as a single 
papule, which may receive recruits from time to time until a 
large part of the larynx is invaded by the hypertrophic process; 
although it may remain circumscribed. The papule may ap- 
parently undergo the process of absorption and pass away ; or 



LUPUS OF THE LARYNX. 419 

it may degenerate and result in ulceration, which is slow, but 
very destructive, and presents a worm-eaten appearance as in 
phthisis. The cicatrices are hard, resulting in permanent hyper- 
trophy and some contracting cicatricial bands, — stenosis. Peri- 
chondritis is comparatively rare, and affects most frequently the 
epiglottis, next the arytenoids, and later the other cartilages. 
Necrosis and exfoliation of the cartilages may occur. Cases are 
reported in which laryngeal phthisis has followed the cure of 
lupus ; the association has not been determined ; it is generally 
believed, however, that the relationship is as "-cause to effect." 

Symptoms. — As already intimated, the early symptoms are 
almost wanting, and are, no doubt, often overlooked. Later, 
the local sensation is one of rawness and scraping. As the dis- 
ease progresses the symptoms become more marked ; cough and 
hoarseness, or aphonia may follow the advent of hypertrophy 
or ulceration ; pain is rare, even during deglutition and phona- 
tion ; if the ulceration be great, the epiglottis may be destroyed, 
resulting in difficult and painful deglutition. 

The laryngoscopic appearances are similar, in some respects, 
to those of syphilis, cancer, and phthisis. The ulcers may be 
situated on either side of the epiglottis, thus simulating phthisis 
(posterior) and syphilis (anterior). The destructive process may 
attack the posterior wall of the larynx (phthisis), one or both 
vocal bands may ulcerate (syphilis or phthisis), and the ulcer be 
round (syphilis) or worm-eaten (phthisis), but the edges are not 
infiltrated as in syphilis, nor is there the circumscribed areola, 
the dusky color to the membrane, or the symmetrical ulcers as 
in syphilis. Necrosis of cartilage is rare in lupus, but frequent 
in syphilis and phthisis. The epiglottis is often pale, but thick- 
ened and sometimes nodular. The laryngeal mucous membrane 
is usually either hyperaemic or congested, but maybe somewhat 
anaemic. Discrete; millet-seed-sized tubercles are sometimes de- 
tected early. In lupus there are frequently new centres of 
ulceration, starting upon points which have cicatrized. — an ap- 
pearance rare in syphilis or phthisis; in the latter there is very 



•420 DISEASES OF THE NOSE AND THROAT. 

little tendency to cicatrization and the cicatrices, when formed, 
do not distort the healthy tissues ; in syphilis the cicatricial 
tissue is very marked and the resultant deformity great ; in 
lupus the tendency to heal is greater than in phthisis and the 
cicatricial contractions arc slight, compared with those of syph- 
ilis. In lupus there is neither the pain nor the emaciation of 
tuberculosis, and there is rarely an involvement of the vocal 
bands or infra-glottic tissues in the ulcerative process, as in 
tuberculosis and syphilis. In lupus hypertrophy is extensive, as 
in syphilis, but the process is more apt to develop slowly and is 
less likely to undergo ulceration. 

Cancer often causes pain and usually occurs in elderly per- 
sons ; lupus in the young. Cancer is usually unilateral and cir- 
cumscribed, with enlarged vessels running over it, and its apex 
is often ulcerated ; the lupoid ulcer is without this vascular pecu- 
liarity and the ulcer is on a broader surface. Dr. Davidson, of 
Florence, Italy (Romoeo. World, July, 1880), says: "There are 
two forms of scars that are of importance, because they have been 
attributed at one time to scrofula and at another to syphilis. 
These are the radiating scars of the fundus of the pharynx and 
the retractile bridles from thence to the posterior columns of the 
velum. Both varieties are found in lupus." 

Prognosis. — The prognosis is good, so far as life is con- 
cerned, unless cicatricial tissue give rise to dangerous stenosis, 
requiring operation ; but there is a possibility that any instru- 
mentation of this cicatricial tissue may rekindle the ulceration, 
which may be so extensive as to result in fatal haemorrhage, 
septicaemia, or inanition. Lupus runs a very slow course, and 
spontaneous cures are not unusual, while treatment is not with- 
out its frequent and well-deserved laurels. The voice may be 
permanently impaired or lost, and respiratory difficulty so great 
as to necessitate the constant use of the tracheotomy cannula ; 
but, thanks to O'Dwyer, these patients have a brighter future in 
intubation. 

Treatment. — The treatment of lupus requires the use of 



LEPROSY OF THE LARYNX. 421 

local as well as internal remedies. Iodine — preferably iodide 
of glycerin — acts well for the hypertrophic form ; and alum, 
boric acid, lactic acid, thuja, peroxide of hydrogen, or resorcin, 
for the ulcerative variety. The curette and galvano-cautery 
occasionally aid in limiting the spread of the ulceration. Should 
the process be one of decided hypertrophy, dyspnoea may re- 
quire tracheotomy or intubation. If the cartilages be exfoliated, 
suffocation may follow their impaction within the lumen of 
the larynx, trachea, or bronchi ; the cartilage thus becomes a 
foreign body and may be removed with forceps, or require 
tracheotomy. When diseased cartilage exists, it may be best 
to cut down to it from without and curette or remove it. 

Internally, ars. alb. and iod., calc. carb. and iocl., fer. iod., 
hepar, and sulphur are indicated. If complicated with syphilis, 
iodine, kali bi., kali iod., mere, proto-iod., mere, sol., nitric 
acid, phos., and thuja, particularly for the ulcerative variety. 
Jousset especially recommends hydrastis 3 x, and E. B. Ivatts 
calotropis gigantea ; the latter causes a discharge of pus and in- 
creases the appetite and weight (Homoeo. World, April, 1880). 

Hygienic treatment is of decided value ; the patient should 
be kept in the country, in the fresh air, regular exercise ordered, 
and good, nourishing diet prescribed. 

LEPROSY. 

The larynx appears to be affected only after cutaneous 
leprosy has made its appearance, thus greatly aiding the diag- 
nosis. Centuries ago a peculiar rough voice was considered 
sufficient to condemn its possessor to the rank of a " leper " ; 
the injustice of such a stigma is now apparent. 

Pathology. — Its laryngeal manifestations are similar to those 
of tuberculosis. At the time of the tuberculous deposit, occasion- 
ally before, the mucous membrane hypertrophies ; ulceration 
follows and is sometimes so severe as to destroy large portions 
of the larynx, pharynx, and surrounding structures. Little 
papillary excrescences sometimes spring from the surface of the 



422 DISEASES OF THE NOSE AND THROAT. 

mucous membrane ; they later undergo ulceration. The prog- 
ress of leprosy of the larynx is very slow. The chief charac- 
teristic seems to be thickening, which often results in severe 
stenosis, demanding tracheotomy ; but the result is not always 
rendered more favorable by this operation, as the tuberculous 
infiltration may have extended below the end of the tracheotomy 
cannula. 

Symptoms. — Subjectively, there is little on which to build 
a diagnosis. The first and most constant symptom is the 
rough voice, which is deep and evidently produced by the vibra- 
tion of thickened tissue. Cough may be present, pain is usual, 
and in the late stages dyspnoea is a prominent symptom. The 
pharynx may be thickened or even ulcerated, the epiglottis is 
usually either infiltrated or ulcerated, and the larynx under- 
goes similar changes within its interior. Its upper boundary is 
nearly always thickened, its aperture narrowed, and the covering 
of the arytenoids thickened. The mucous membrane is usually 
dark in color, and often hangs as though detached from the 
underlying structures. 

Prognosis. — The prognosis does not differ from that of the 
general disease, unless the hypertrophy be severe enough to 
result in stenosis, or the ulcerative or hypertrophic process inter- 
fere with deglutition ; in either of these instances death occurs 
earlier than in the general affection. An occasional case is said 
to recover. 

Treatment. — As yet the treatment has not proved very 
satisfactory. All attempts to localize the disease by the cautery, 
spoon, gouge, or curette are futile and only hasten the fatal 
termination. Any local means that can be found to give com- 
fort should be employed ; of these the spray (see " Chronic 
Laryngitis ") is generally the most useful. Iodine applications 
are best indicated symptomatically, but do not prove more than 
palliative. 

Internally, graphites would seem to be the most similar 
drug, but bovista, hydrocotyle, iodine, sulph., and thuja offer 
points for consideration. 



LARYNGEAL TUBERCULOSIS. 423 

LARYNGEAL TUBERCULOSIS — LARYNGEAL PHTHISIS THROAT 

CONSUMPTION. 

The post-mortem cases of Demme, W. H. B. Aikins, and 
others, now render certain the previous conjectures that laryn- 
geal tuberculosis might be a primary affection. A few years 
ago the evidence seemed to be on the other side. It is now 
possible to trace the progress of the primary symptoms, by 
which a diagnosis of the condition can frequently be made suffi- 
ciently early to abort the dread affection and save the patient 
from his otherwise almost certain doom. While this is possible, 
it must be borne in mind that the vast majority of patients do 
not consult the physician in this early stage, and after the 
affection is once fully established it seems impossible to cure 
more than a small percentage of the cases ; but it is not unlikely 
that in the near future phthisis laryngea will be classed with 
the generally curable maladies. It is characteristically a chronic 
disease, but there are instances in which it is acute and miliary 
in nature ; the latter are rare, comparatively speaking, and 
usually affect the mouth and pharynx as well as the larynx. 
This variety is rapidly fatal, the patient surviving but a few 
weeks, or, at most, a few months. 

Etiology. — Etiologically, tuberculosis of the larynx differs 
but little from that affection when attacking other organs ; there 
is the same hereditary tendency ; the lowered vitality with loss 
of tone repair, hereditary or acquired ; lack of hygienic and 
dietetic precautions ; sedentary, in-door life ; and influence of 
sex and age. In addition to the preceding there is the possi- 
bility and frequent reality of a catarrhal condition of the larynx 
as a stepping-stone to the graver affection. Some have claimed 
that the vocal function tends toward a development of phthisis 
of the larynx in those who are weakened; but it is more prob- 
able that this function, if properly performed, will benefit rather 
than endanger the possessor of tuberculous tendencies. Two- 
thirds of the cases of throat consumption occur in males, mostly 
between the twentieth and thirtieth years. 



424 DISEASES OF THE NOSE AND THROAT. 

Pathology. — The pathology of laryngeal tuberculosis is 
not markedly different from the same affection when occurring 
elsewhere, but there is a greater variety of appearances mani- 
fest to the eye here than in tuberculosis of the deeper parts ; 
so that the various stages of hyperaemia (acute), anaemia (chronic), 
infiltration, ulceration, necrosis, and caries, or new formations 
may be studied laryngoscopically as the disease progresses. The 
infiltration is in part a serous oedema, but is chiefly due to an 
invasion of the submucous tissue with tubercles ; a true oedema 
may occur from a tubercular perichondritis. The laryngeal 
muscles may be infiltrated, giving rise to vocal defects ; and 
ankylosis or dislocation of the crico-arytenoid joint may give 
rise to a fixed position of the vocal bands. In the ulcerative 
stage tubercle bacilli are always found in large quantities ; they 
are less constant earlier in the disease. Necrosis or caries may 
attack any of the laryngeal cartilages; new growths often appear, 
and are either granular, cauliflower-like masses (granulomata, 
granuloid hyperplasia) or wart-like (papillomatoid) excrescences; 
they are sometimes precursors of the affection. Their usual 
situations are the base of the epiglottis, the interarytenoid com- 
missure, and the subglottic cavity. They are pale-white, yellow, 
or pink in color; soft and easily knocked off or removed by 
forceps ; grow rapidly ; and may cause serious dyspnoea. 

Symptoms. — The symptoms of the acute form are : sharp 
pain when speaking or swallowing, and sometimes when breath- 
ing. The temperature soon rises, at times reaching 104° F. ; 
malaise is one of the most pronounced symptoms. Emaciation 
is not the rule, as the patient often succumbs to some meningeal 
complication before that stage is reached. General tuberculosis 
sometimes supervenes; this may appear in the retinas in the form 
of minute tuberculous points, or a large number of these 
little dots may be seen studding the mucous membrane of 
the pharynx and tongue ; they frequently coalesce and form 
one or more masses of deposit, which sooner or later ulcerate. 
The larynx manifests the same process and the ulceration rapidly 



LARYNGEAL TUBERCULOSIS. 425 

passes through the various stages to be described in the chronic 
condition. The prognosis is very grave. 

Chronic laryngeal phthisis is divided into four or five 
stages, depending upon the authority, some writers not consid- 
ering anaemia a distinct division. These stages, although not 
always strictly separable, have, nevertheless, an existence. 
Anaemia is a well-known condition of the primary stage of 
the chronic affection, while in the acute variety congestion 
almost always takes its place ; the stages of deposit or infiltra- 
tion, ulceration, necrosis or caries, and new formations are often 
distinguishable, although ulceration, necrosis, and new forma- 
tions (occasionally the only manifestation) frequently appear in 
rapid succession. 

If a patient complain of a sudden functional loss of voice, 
the thought should be: "a possible phthisis;" and this thought 
should become almost conviction if, in addition, a slight anaemia 
of the greater part of the pharynx exist, together with spots of 
hyperaemia ; in other words, an " anaemio-hyperaemia," as noted 
by the author in the Trans, of the Homoeo. Med. Soc. Pa., 
1883. This anaemia is also often associated with fugitive blush- 
ing and abnormal sensitiveness. Although this is almost a posi- 
tive indication, the confirmatory conditions exist in the spacious 
pharynx, due to the separation of the soft palate and uvula from 
the posterior pharyngeal wall ; the tremulous uvula and soft 
palate and, as pointed out by Dr. C. E. Beebe, "the entire mem- 
brane can be seen moving constantly in different directions on 
the submucous tissue." The larynx is usually anaemic, with 
numerous spots of congestion. The vocal bands are often dirty, 
dingy-looking, and the entrances to the laryngeal sinuses fre- 
quently present a dark, purplish tinge. The chest-sounds may 
be normal, there may be slight sacculated inspiration, or ex- 
amination may denote well-advanced phthisis. Schrotter looks 
upon a unilateral laryngeal catarrh as a frequent indication of 
throat consumption. 



426 DISEASES OF THE NOSE AND THROAT. 

I am pleased to agree with Dr. Rene Sarrand {El Con- 
suitor Homceopatico, October, 1888), "that in those persons des- 
tined to suffer phthisis pulmonalis there always exist pharyngo- 
laryngeal signs, very positive, very constant, that precede by 
much the pulmonary signs." To this he adds : " These signs 
are three: 1. Pharyngeal anaemia ; the pharynx is pale, dis- 
colored, and blanched. 2. Faulty approximation of the vocal 
bands, with atony of the constrictors. 3. Congestion of the 
arytenoid and interarytenoid mucous membrane, changing into 
an inflammation and a cherry-red coloration of this region." 
" It is here," he continues, 4i that Drosera rotundifolia, given 
perseveringly, produces remarkable effects, and where this 
remedy merits the name of a preventive of phthisis pulmonalis." 




Fig. 115.— Laryngeal Phthisis, showing Pyriform Arytenoids and 
Ulceration of Left Vocal Band. 

When the anaemic stage is not arrested, the larynx assumes 
more a condition of congestion, and in this the pharynx shares. 
Some portion of the larynx presents evidences of an infiltration 
or deposit, which sometimes shows itself in the form of little 
elevations similar to those seen in follicular pharyngitis or laryn- 
gitis. If the ary-epiglottic fold present a pyriform swelling, 
the diagnosis is an assured fact ; this swelling of the arytenoids 
is unmistakable ; the body of the pear is represented by the 
arytenoid itself, while the smaller stem-end gradually tapers off 
and is lost in the ary-epiglottic fold near the epiglottis : one or 
both cartilages may be affected. In this stage the lungs are not 
usually broken down, but when the epiglottis takes on its turban- 
like swelling the pulmonary structures are usually much soft- 



LARYNGEAL TUBERCULOSIS. 427 

ened. In some cases, however, the lungs show no evidence of 
the phthisical change for some months later ; well-marked laryn- 
geal ulceration may exist when repeated chest examinations, by 
expert diagnosticians, fail to detect the presence of pulmonary 
changes. If with the first evidence of laryngeal phthisis (the 
anaemia, etc.), I find the peculiar wavy (sacculated) respiration 
over either apex, during several successive inspirations, I feel 
safe in pronouncing the condition phthisis, even if the laryngeal 
changes be not entirely characteristic. 

In the second stage, the patient often has a partial or com- 
plete loss of voice and a decided and annoying cough, with ex- 
pectoration of thick, yellowish, or greenish mucus. There is 
usually loss of appetite and, in many instances, loss of flesh as 
well ; sometimes there is complaint of pain in the larynx, but 
this is not marked unless there be decided deposits in the 
epiglottis, preventing prompt and painless action of this carti- 
lage, or where the pyriform swelling of the arytenoids is exten- 
sive, thereby interfering with the easy passage of food. Cough 
is one of the most annoying and intractable conditions. In the 
stage of deposit the sufferer not infrequently complains of pain 
running up to the ear when swallowing ; during the stage of 
ulceration the pain may be continuous and often changes from 
ear to ear, seldom affecting both at the same time. This symp- 
tom, if* long-lasting, belongs prominently to phthisis, but is not 
infrequent in cancer of the larynx. 

In the stage of laryngeal ulceration the symptoms are 
all aggravated ; the voice is peculiarly deep, hollow, or hoarse, 
if, indeed, it be not entirely suppressed ; the latter is usual when 
the ulceration attacks the parts contiguous to the vocal bands, 
or when the infiltration occurs in the transverse muscle or 
region of the arytenoids. The posterior wall of the larynx is 
not infrequently ulcerated, when spiculae of loosened tissue 
often project between the vocal bands. Tuberculo-papilloma- 
tous growths may appear in the posterior commissure, at the 
base of the epiglottis, under the vocal bands, more rarely on 



428 DISEASES OF THE NOSE AND THROAT. 

the vocal or ventricular bands, or in the ventricles. They occa- 
sionally appear as primary manifestations of phthisis, consisting 
of true tubercular tumors varying in size from a pea to a 
chestnut, when they should not be disturbed, mechanically, as 
operation is said to release the germs of infection previously 
inclosed in the tumor. 

When ulceration attacks the epiglottis, the posterior sur- 
face usually suffers first, although the entire cartilage may be 
destroyed later ; even when perforated the contour of the organ 
may be unaffected, thus excluding syphilis. When destroyed, 
the patient often complains of dysphagia and of food entering 
the larynx. Ulceration of the vocal bands may be confined to 
a superficial, small, circumscribed, oval area with congested 
borders ; the free edge of one or of both bands may be ragged ; 
or a great part of one or both be destroyed. The ulcers of 
phthisis are usually multiple and at first superficial, with some- 
what congested edges ; later, they become rather deep and often 
coalesce to form one large mass with an irregular, worm-eaten 
appearance ; the edges being surrounded, according to Frankel, 
by yellow deposits of miliary tubercles. While these ulcers 
nearly always contain tubercles (difficult to heal), sometimes 
they are non-tuberculous (easy to heal) and are quite superficial 
(lenticular, aphthous, corrosive, infective, membranous, or diph- 
theritic 1). The surface is covered with dirty-yellow mucus and 
the surrounding tissues are pale and ashy in color. The ulcer 
is, apparently, not below the surface, as the space destroyed is 
immediately filled with granulation tissue, unless the epiglottis 
or vocal bands be attacked, when total destruction may follow. 
The small, multiple, ragged-edged ulcers may appear on a pale, 
cedematous surface. 

All tuberculous ulcers are sluggish, have little tendency to 
heal, but when healed are rarely, if ever, followed by cica- 
tricial distortions, as in the cicatrization of syphilitic ulcers. 
When ulceration attacks the vocal bands or their surrounding 
tissues, the voice is either destroyed or very changeable ; a por- 



LARYNGEAL TUBERCULOSIS. 429 

tion of a word or one, two, or more words may be quite clear, 
with the succeeding sounds whispered ; in rare instances there 
may be double voice (diphthonia). Immobility of the vocal 
bands is due to infiltration, ulceration, or pressure upon a muscle 
or nerve. The right recurrent may suffer from pleuritic adhe- 
sions and tuberculous deposits in the right upper chest. 

In the later stages of laryngeal phthisis the suffering is 
frequently very great ; the larynx is the seat of almost constant 
pain ; deglutition is often impossible ; food passes into the 
larynx or even into the trachea and bronchi, where it usually 
gives rise to secondary bronchitis, or even fatal pneumonia ; 
cough is frequent, ineffectual, and distressing. The ulceration 
is nearly always attended by profuse muco-purulent, purulent, or 
even a sanguineous discharge. It frequently contains broken- 
down epithelium and pieces of sol't or even cartilaginous tissue. 
Often in the later stages, when, from the swelling, ulceration, 
and general loss of strength, the patient is unable to expecto- 
rate freely, the vallecula, the pyriform sinuses, and even a part 
of the cavity of the larynx become filled with these discharges 
and debris, thus preventing a clear view of the vocal organ. In 
this stage perichondritis and chondritis often result ; the voice 
is usually lost and ankylosis or dislocation may occur at the 
crico-arytenoid joints ; the smaller cartilages may be destroyed 
and exfoliated, and portions, rarely all, of the larger ones occa- 
sionally share a like fate. As a rule, these loosened pieces are 
expectorated ; occasionally they require removal by the aid of 
laryngeal forceps ; and rarely they cause fatal laryngeal stenosis 
or, passing into the deeper respiratory tract, induce early death. 
Haemorrhages, ulcerative in origin, are rare and never imme- 
diately fatal. 

Diagnosis. — From cancer the distinction is generally easy ; 
there is the single, hard growth ; the frequently shooting pains ; 
ulceration occurs usually at one point ; the structures involved 
have an angry, active appearance ; and the ulcer is deep and 
irregular, and not worm-eaten, as in phthisis. In both diseases 



430 DISEASES OF THE NOSE AND THROAT. 

pain may extend to the ears ; the haemorrhages of cancer are 
often characteristic. 

Chronic oedema of the larynx is more transparent, clear, 
and waxen than the dull, translucent, partially solid deposit, 
with a thin layer of effusion, of tuberculosis. 

Chronic laryngeal catarrh is often difficult to differentiate 
from the early stages of chronic laryngeal phthisis ; but the 
more uniform congestion of the former usually contrasts with 
the more circumscribed congestion and the aneemic condition of 
the latter, in which there are, also, usually noted the other 
early changes described. 

It may be said that, in 90 per cent of the cases examined, 
the laryngoscope furnishes an exact means of diagnosis of laryn- 
geal consumption, and the laryngologist can often diagnose 
phthisis where the so-called physical signs prove negative. He 
may thus warn of the prospective dissolution in time to save 
the patient's life. 

Prognosis. — Although a few cases recover from the disease 
after it is well established, patients usually die in from six 
months to two or three years, although occasionally throat con- 
sumption has proved fatal only after six years. It is never safe 
to give a favorable prognosis. At the present time, however, 
the prognosis is not so grave as formerly, and many cases which 
would have, at one time, been considered incurable are now 
restored to comparative health. Other things being equal, the 
earlier the case is seen, the better the prospect of cure ; and, the 
less the interference with deglutition, the greater the chances of 
relief; or, in other words, the less the ulceration of the epiglot- 
tis, arytenoid cartilages, and inter-arytenoid space, the better the 
prognosis. Perichondritis, caries, and necrosis make the outlook 
graver. Stenosis may end life if not relieved by tracheotomy. 

Treatment. — Internal medication is, undoubtedly, of first 
importance, but it must not be forgotten that much may often 
be accomplished by the judicious use of adjuvants, and that 
surgical interference is sometimes advisable. Many laryngolo- 



LARYNGEAL TUBERCULOSIS. 431 

gists, including Krause (who introduced lactic acid for the cure 
of laryngeal phthisis) and Heryng, strongly recommend the use 
of the curette or spoon (as introduced by the latter). More 
recently, Prof. Krause practices actual excision of the cedema- 
tous tissue ; his experiences are very encouraging, but the success 
of many other operators has been less nattering. According to 
one report, he had treated seventy-one cases by the curette, out 
of which forty-one were cured, or at least there was a remarka- 
ble amelioration, with disappearance of the painful phenomena. 
The larynx is thoroughly cocainized before these operations: 
Heryng then scrapes the surface of the ulcer with a sharp, 
laryngeal curette ; as soon as the bleeding ceases lactic acid is 
applied. Krause removes all cedematous, as well as ulcerative, 
tissue with a forceps-curette ; lactic acid is then applied. Both 
operators insist not only that the surface of the denuded tissue 
be thoroughly painted, but actually soaked in the acid, and that 
the saturated cotton pledget be forcibly rubbed over the surface- 
The solution varies from 20 to 50 per cent. 

The galvano-cautery has been highly extolled by many. 
Heryng has had some very gratifying results from electrolysis 
{Cong. Inter, cle Lar., Paris, September, 1889). Local reme- 
dies may be used in the form of spray, inhalation, insufflation, 
or be applied by brush or cottoned probe ; if a spray be used, 
benzoinol, fluid albolene, fluid cosmolin, warm vaselin, olive- 
oil, oil of sweet almonds, or glycerin may be used as a vehicle. 
The best spray medicaments are: eucalyptol, 10 per cent; 
calendula, 20 per cent in water ; carbolic acid, 1 per cent ; 
camphorated naphthol ; and menthol, 1 to 5 per cent, the latter 
acting as an anaesthetic, antiseptic, and stimulant. The best 
inhalations are : eucalyptus globulus, vapor of menthol, and 
pine-oil. Insufflations are at times indicated, either to relieve 
pain or to excite cicatrization ; for the former, morphine acetate, 
one-eighth to one-sixteenth of a grain to three grains of starch, 
should be insufflated about one-half hour before eating; for 
the latter, aristol, boric acid, iodoform, and iodol act best. 



432 DISEASES OF THE NOSE AND THROAT. 

Morphine is now often supplanted, with advantage, by cocaine 
hydrochlorate, 4-per-cent solution ; but one of the best applica- 
tions, for relieving pain, is a spray of a watery solution of 
calendula officinalis, " 1 to 20, or weaker, with the addition of 
two or three drops of carbolic acid to the ounce," as recom- 
mended to me by Dr. A. C. Peterson, of San Francisco. In 
his note (November 20, 1889) the doctor states: "In one case 
especially, where it was absolutely essential to deaden the 
excruciating pain caused by the act of swallowing, calendula 
spray, used once a day, within a week quieted the inflammatory 
and ulcerative conditions in so marked a manner that the patient 
was but merely conscious of the throat and larynx ; this happy 
relief remained with the patient until death." Cannabis sat. 
(10 per cent) often acts similarly. 

As direct healing applications, lactic acid stands first ; men- 
thol, peroxide of hydrogen, pyoktanin, and calendula following. 
Menthol acts more slowly than lactic acid, but is less painful, 
and my short experience with calendula bids fair to place it at 
the head of the list. 

Meyhoffer wrote: "We use argent, nitric, in all its 
preparations ; from the second and third potency to the local 
application of the lunar caustic, and from 1 to 6 grains to an 
ounce of water for inhalations. Nitrate of silver proves a highly 
beneficial agent in all the stages of tuberculous laryngitis ; in 
the beginning of the disease, when the throat and larynx are 
much inflamed, and with titillation in the latter, much hawking 
or spasmodic cough, and accumulation of phlegm in the throat. 
At a later period, when the edges of the ulcers are the seat of 
luxuriant granulations, the inhalations of the stronger solutions 
of this salt produce excellent effects, as they reduce the morbid 
growths." Dry, spasmodic cough, hoarseness, aphonia, and 
perichondritis are indications for the remedy. A few patients 
have complained of intolerable itching, as though they must 
scratch the larynx, or as though it were fissured, " as in chapped 
lips"; for this I have never seen an application of a 10-grain 



LARYNGEAL TUBERCULOSIS. 433 

solution fail to give relief, lasting from twelve to forty-eight 
hours. 

Food should be mild and yet nourishing; semi-fluids are 
less likely to enter the larynx ; fluids should be slightly thick- 
ened with rice-flour, corn-starch, arrowroot, or Irish-moss de- 
coction. Wine-whey is much used, and justly so. Raw oysters 
are often grateful, and raw eggs, the yelks of which are un- 
broken, answer well in a large number of cases. Rich milk 
should be taken freely and frequently. Spices, condiments, and 
acids should be avoided, but the juice of sweet fruits often relieves 
thirst. The patient should be instructed to swallow quite large 
mouthfuls rather than to sip his food. If deglutition be prac- 
tically impossible, owing either to uncontrollable pain or to the 
entrance of food into the larynx, the patient should be fed with 
an oesophageal tube or given nutrient rectal enemata. 

The advisability of tracheotomy in laryngeal phthisis is a 
point which has received much discussion ; it is usually recom- 
mended only where dyspnoea is marked and constant, and to 
this advice, if scarification be contra-indicated, there can be but 
doubtful exception. Many go further, however, and urge an 
early operation for the purpose of giving rest to the larynx, 
especially where odonphagia exists. Moritz Schmidt advises 
tracheotomy where there is marked laryngeal disease with com- 
paratively healthy lungs, in rapidly-advancing laryngeal phthisis 
before the appearance of dyspnoea, and where stenosis exists ; 
but, above all, if dysphagia be present; and he believes that the 
lungs themselves may heal afterward. It must not be forgotten 
that a fatal pneumonia occasionally follows tracheotomy. Mac- 
kenzie (in 1889) had never seen benefit from tracheotomy unless 
dyspnoea were present, and thinks the patient is less comfortable 
after it, on account of the difficulty in expectoration and the irrita- 
tion caused by the cannula. There is little doubt that a marked 
engorgement of the lungs may be relieved, but I have never felt 
it prudent to operate in the absence of dyspnoea ; in such cases, 
however, I have been greatly pleased with the results. 



434 DISEASES OF THE NOSE AND THROAT. 

Therapeutics. 

Ars. — "The leading symptoms are: a dirty-red or anaemic 
appearance of the laryngeal lining, with bluish-red patches, or 
general discoloration of the tissues ; indolent, or burning, ex- 
tensive ulceration, with more or less sero-purulent secretion." 
(Meyhoffer.) Dr. E. C. Jones {Trans. Horn. Med. Soc. State of 
N. Y., 1879) recommends it where the laryngeal membrane is 
anaemic, stained with dirty-looking spots " and marked by the 
velvety projections which presage coming ulcerations. Cough 
is absent or entirely out of proportion to the progressive emaci- 
ation or picture imaged in the laryngeal mirror." He also 
recommends this remedy in the latter stage with extensive in- 
dolent ulceration, and acrid, sero-purulent discharge. He con- 
tinues, "It is well, also, to apply this greatest of all nutritive 
stimulants topically by means of the spray," and makes use of 
an aqueous solution of the sodas arsenitis. Frequently there is, 
also, intense burning in the larynx, especially with flat and 
purplish ulceration and serous infiltration. 

Carbonate of potassium or sodium (3 to 10 grains to the 
ounce) is useful, as a spray, in assisting the expectoration of 
thick, tenacious, profuse secretions. 

Drosera rot. — For children of consumptive parents, Dr. 
Rene Sarrand considers this drug prophylactic (Homoeo. Re- 
corder, January 15, 1889), and adds: "Dr. Curie affirms that 
in the initial period of phthisis it is nearly always possible to 
gain a cure through drosera."" 

Fer. phos., in the early stages, often checks further de- 
velopment and is useful for the loss of control over the tensor 
muscles of the larynx. 

Iodine is of undoubted value in phthisis complicated by 
scrofula, when the a ry -epiglottic and inter-arytenoid folds are 
chronically thickened, the result of proliferation of connective- 
tissue elements. Ulceration, muco-purulent or bloody expectora- 
tion, and tightness and soreness in the larynx, referable to one 
spot. 



THERAPEUTICS OF LARYNGEAL TUBERCULOSIS. 435 

Merc. nit. — Dr. Malcolm Leal advises the use of this remedy 
" in ulcerative stomatitis and in laryngeal tubercular ulcerations 
of small size, several of which have disappeared under its use." 

Nitric ac. — " Great irritation ; redness or anaemia ; violent 
dry cough, spasmodic, choking, and exhausting. It will furnish, 
in some of the severe laryngeal coughs, brilliant results, reliev- 
ing the attacks promptly and for a considerable period." (Dr. 
J. S. Mitchell, "Arndt's System of Med."). I have repeatedly 
dissipated a sharp, knife-like pain in the left side of the larynx 
with nitric ac. 30 x. 

Phos. is a remedy of great value. The marked symptoms 
are : hoarseness or aphonia ; larynx raw and sore ; inspiration 
wheezing ; hectic fever with progressive emaciation ; larynx 
sore when speaking and coughing, and when pressed upon. 

Selenium. — Cough and expulsion of small lumps of clear, 
starchy mucus or blood from the larynx ; hoarseness as soon as 
one begins to sing, or after long singing or speaking. Indicated 
both in the early stages and after ulceration has occurred, but 
Its action seems to fail in the later stages. 

Stan. — Mucous membrane dirty-looking, vocal bands ulcer- 
ated; constant, short, irritating cough. 

The following extracts are from a letter dated " Nice, De- 
cember 28, 1889," from the late Dr. John Meyhoffer; he who 
did such noble work in the early days of the laryngoscope (see 
" Chronic Diseases of the Organs of Respiration "). It seems 
but fitting to close this subject by making these quotations from 
his handwriting, penned just before the close of a life rich in 
medical experience : — 

" Lymphatic dispositions, even strumous diatheses, present 
fair chances of recovery. This assertion is contrary to all 
traditions ; yet it is nevertheless true, and that for two reasons : 
1. The course of the disease, in such individuals, is generally 
slow and leaves, therefore, more time for medication. 2. We 
can rely on a positive curative influence of a certain class of 
medical agents, the iodides. 



436 DISEASES OF THE NOSE AND THROAT. 

" The iodides of kalium, natrium, and calcium, of use 
chiefly as modifiers of the constitution and the diathesis. The 
preparations used are, usually, 1 x, 5 drops twice a day for two 
consecutive days, followed by a week's rest. Their influence is, 
however, not less marked on the lining of the larynx ; the 
ulcers assume a better aspect and show a tendency to cicatrize. 

" The iodides of mercury are of great service when there 
is much congestion, swelling, and redness in any part of the 
laryngeal lining ; healing ulceration. I commend to your 
attention the ars. jodat., 3 x trit., in cases of deficient nutrition, 
when, notwithstanding a good appetite, the patient loses weight. 

" The iodide of baryta is to be preferred in enlargement 
of the tonsils and general indolent swelling of the glands of 
the neck. 

" The aurum jodat., 3 x trit., I have found very useful in 
torpid ulcerations of the larynx, which resisted all other rem- 
edies, whether topical or internal. From the moment this agent 
came into action, there appeared almost immediately great vas- 
cular activity in the diseased parts, and the torpid ulcers made 
rapid strides toward healing. In one case which resisted for 
months the other iodine preparations, the cicatrization of the 
ulcers on the arytenoid lining was brought about in three weeks. 
In none of the cases where the iodide of gold did good service 
could I trace any syphilitic taint. 

" In my work you will find (page 148) a case of recovery 
of phthisis laryngis under the influence of selenium natr. Since 
then this salt, though very useful in many other respects, has 
disappointed me in this disease. 

" I can only consider as correctives those auxiliaries which 
co-operate in the direction of the internal remedies. Hence, as 
long as I can see any chance of restoring the diseased parts of 
the larynx to a healthy condition, I abstain, as much as possible, 
from any local remedy which is not in harmony with the internal 
treatment. Ioduretted vapours, as pulverized liquids, play, 
therefore, the principal curative role of local applications under 



THERAPEUTICS OF LARYNGEAL TUBERCULOSIS. 437 

the following formulae : kali jodat., pure, gr. ij ; aqua, giv ; 
and natr. jod., gr. iij ; aqua, gv; to be pulverized and inhaled 
by the aid of Siegel's steam apparatus. 

" As palliatives, I use, when there is distressing cough and 
difficulty of deglutition, strong solutions of bromide of potash 
or hydrochlorate of cocaine, applied, loco dolente, with the brush 
before meals : ty Bromide of potash, 3j ; glycerin pure and aqua, 
aa, gss. 1^ Cocaine hydrochlorate, gr. xv; glycerin pure, Sj." 



CHAPTER XXXII. 

Syphilis and Stenosis. 



SYPHILIS OF THE LARYNX. 

Etiology. — It is scarcely necessary to state that primary 
syphilis of the larynx must be a very rare condition — if, indeed, 
it ever occur. It could only happen through the contact of 
virus carried to the part with the laryngologist's instruments. 
It is not rare, however, to find secondary and tertiary laryngeal 
manifestations ; the congenital variety is less frequent. 

Pathology. — The characteristic changes in this affection 
must be studied in connection with the form of the disease 
present. There may be a mild congestion, resembling roseola ; 
a severe inflammation, with ulcerations either superficial or 
deep, and involving the muscles, perichondrium, cartilages, and 
other tissues ; mucous patches ; condylomata, grayish-white in 
color ; marked oedema and syphilitic deposit ; or actual neoplastic 
formations. After destructive ulceration, cicatrices may distort 
the larynx beyond recognition, destroy the voice, and hinder of 
prevent respiration. 

Secondary syphilis may affect the larynx at any time from 
six months to two years after the primary sore ; and the tertiary 
form, from two to forty years after the chancre. A large pro- 
portion, perhaps 20 per cent, of syphilitics have a laryngeal 
complication which may extend from the pharynx by continuity, 
or more frequently attack the larynx independently. 

In mild secondary syphilis the symptoms are essentially 
those of the early stage of subacute laryngitis. As a rule, there 
are, at this time, no cutaneous evidences of syphilis, and none 
may have been noted by the patient ; in some there is enlarge- 
ment of the post-cervical glands and involvement of the phar- 
ynx, but the latter usually suffers at an earlier date ; so that the 
(438) 



SYPHILIS OF THE LARYNX. 439 

diagnosis may be dependent upon the laryngoscope alone. 
When superficial ulceration occurs, there is a purulent or muco- 
purulent expectoration. The vocal bands are congested in 
patches and grayish in color ; the lining membrane is of a dull, 
mottled red. The two sides of the larynx are often symmetri- 
cally affected. The hyperaemia is duller in color and more 
below the surface than in chronic laryngeal catarrh. If care- 
fully watched, mucous patches may be seen to develop at the 
mottled points, and in a few days be supplanted by multiple 
superficial ulcers, which are usually oval and covered with a 
dirty-yellow discharge, which, when sprayed or carefully wiped 
off, appear bright-red, but do not actually bleed. These super- 
ficial ulcers, which are surrounded by a deep-red zone, never 
degenerate into the deep ulcers of tertiary syphilis ; the latter 
are characteristic from the first. When the epiglottis is ulcer- 
ated, there is usually difficult deglutition, and food may enter 
the larynx. Condylomata occasionally occur in the secondary 
form, and, although they generally appear on the epiglottis, 
they are not confined to it ; they sometimes become apparently 
warty growths. 

Secondary syphilis of the larynx is characterized by its 
amenability to treatment and its tendency to relapses. This 
last-mentioned characteristic caused Whistler to designate a 
" relapsing, ulcerative laryngitis," which he considers an inter- 
mediate stage of syphilis, but which it seems proper to call 
secondary. 

Tertiary syphilis presents oedema, condylomata, gummatous 
tumors, ulceration, necrosis, caries, stenosis, etc. When deep 
ulceration occurs, the symptoms are very different from those 
noted under superficial, secondary ulcers ; thus, cough is often 
annoying ; expectoration is very profuse, and consists of mucus, 
pus, blood, broken-down epithelium, fibres of the firmer and 
deeper tissues, and sometimes necrosed and caried cartilages. 
The voice is rarely affected if the epiglottis alone be ulcerated; 
otherwise it is lost, often irrevocably. Respiration is impaired 






440 DISEASES OF THE NOSE AND THROAT. 

when oedema, cicatricial bands, or new growths encroach upon 
the glottic space, or when there is paralysis of the posterior 
crico-arytenoid muscles, ankylotic fixation of the vocal bands 
in the approximated position, or strictures of the trachea. Any 
of these may cause stridulous cough or asthmatic and suffocative 
attacks, following exercise, excitement, or spasm. These may 
prove suddenly fatal, or, growing very frequent, cause death by 
exhaustion. Laryngeal pain is unusual except during deglu- 
tition, when food frequently enters the larynx, perhaps causing 
severe dyspnoea. 

The deep ulcer is usually single, but may be multiple ; it 
appears to develop slowly ; generally there seems to be no ex- 
plainable cause for its development, but it may originate from de- 
generation of a gummatous growth or mucous patch. It presents 
an irregular crescentic outline, with raised, ragged edges, and 
has a slight inflammatory areola ; its floor is covered with a 
■dirty, yellowish-white coating. The epiglottis rarely escapes 
the deep ulcers of syphilis ; it may be notched, when the edges 
of the ulceration are clean-cut, or the cartilage may be entirely 
destroyed. From the epiglottis the ulceration may extend to 
the ary-epiglottic folds, and, finally, to the ventricular and vocal 
bands. The arytenoid cartilages and posterior wall of the 
larynx are rarely ulcerated, except as the result of extension 
from other parts ; although a gumma may form in the inter- 
arytenoid tissue and degenerate. As the ulceration extends and 
the deeper structures are involved, the laryngoscopic picture 
may become so distorted as to render the larynx almost irrecog- 
nizable ; sometimes good-sized pieces of the cartilage are de- 
stroyed and cast off in the debris, but haemorrhages are rarely 
severe. 

The normal color of the mucous membrane may be exag- 
gerated, but, as a rule, it is rather dull, — almost purple ; and is 
usually deprived of its normal velvety appearance ; it may even 
impart a grayish-yellow appearance, owing to chronic submu- 
cous changes ; the vocal bands may lose their lustre, be con- 



SYPHILIS OF THE LARYNX. 441 

gested, ulcerated, or, in great part, destroyed. Gummata are 
generally the color of the surrounding mucous membrane, but, 
when on the epiglottis, are often paler ; as they approach the 
stage of ulceration their centres are apt to assume a yellowish, 
tinge. Generally the pharynx and soft palate show evidences 
of the syphilitic condition, if, indeed, they be not actually 
ulcerated. 

The cicatricial thickening is the result of excessive growth 
of the tissue elements directly surrounding the ulcer, the base 
of which is but slightly active, which is the reverse of the cica- 
trices of phthisical ulceration ; on this account syphilitic ulcers 
often heal, leaving extensive increase of tissue and marked dis- 
tortions. One characteristic of this excessive tissue growth is 
its hard, dense consistency, which renders it most difficult to 
reduce; when cut or dilated it is prone to return to its former 
state. 

Diagnosis. — The history of the affection and the cutaneous 
appearances usually aid the diagnosis, and yet it not infrequently 
happens that there are no general indications of syphilis. 

Two of the distinguishing features of syphilitic ulceration 
are : the usual absence of pain and the inflammatory areola 
which surrounds the ulcers; in phthisis the pain may be con- 
stant, but aggravated by deglutition, and the surrounding tissue 
is rather anaemic. In syphilis the superficial ulcers are usually 
multiple and generally oval, with dark-red areola? ; those of 
phthisis, though frequently multiple, are usually very irregular 
in outline. The deep ulcers of syphilis are generally single with 
overhanging edges, and occupy the sides of the organ ; in phthisis, 
on the other hand, the ulcers are not deep, and are prone to at- 
tack the posterior portion. In syphilis, the anterior portion of 
the epiglottis suffers more; in phthisis, the posterior surface. 
The ulcers of syphilis show a tendency to heal readily and leave 
marked cicatricial deformities ; those of phthisis heal very slug- 
gishly and leave almost no deformity, the ulcer filling with gran- 
ulation tissue almost as fast as the process of destruction goes. 



442 DISEASES OF THE NOSE AND THROAT. 

on. Syphilitic ulceration is an acute process; phthisical, usually 
chronic. The ulcers of syphilis often attack the pharynx ; those 
of phthisis rarely. The syphilitic mucous membrane is purplish ; 
phthisical, anaemic (see " Laryngeal Phthisis "). 

In phthisis and cancer there is usually lancinating pain, 
which extends along the Eustachian tubes to the ears; this is rare 
in syphilis. Deglutition is usually difficult, painful, or impossible 
in phthisis and cancer ; rarely marked in syphilis except in ad- 
enitis. Cancerous ulceration requires weeks for its development ; 
tuberculous, months ; syphilitic, a few days. The anterior and 
posterior cervical glands are affected in syphilis ; the posterior, 
rarely in cancer and never in phthisis ; the anterior may be in- 
volved in either. More characteristic lymphatic enlargements 
are found, however, at the cornua of the hyoid bone ; very early 
affected in most cases of cancer ; late and occasionally in syphi- 
lis and phthisis. A fibroid degeneration is an infrequent tertiary 
syphilitic change; this sometimes undergoes ulceration, from 
which cancer can best be differentiated by consideration of the 
previous history and the co-existing syphilitic lesions. Lupus 
shows some general resemblance to syphilis, but it is very rare 
and always presents other distinctive manifestations. 

Prognosis. — The outlook for secondary syphilis of the 
larynx is good, with the exception of the occasional loss of the 
singing voice, chronic hoarseness, and the formation of new 
growths. The tertiary variety is not so favorable ; perichondri- 
tis, especially of the cricoid cartilage, marked cicatricial steno- 
sis, or acute oedema, may suddenly prove fatal ; haemorrhages 
are rarely serious. On the other hand, early and careful treat- 
ment will usually carry the patient through this severe condition 
with some evidence of impaired function only ; thus, a lost epi- 
glottis may somewhat interfere with deglutition, but, if the 
sphincter and adductor muscles be unimpaired, the act may be 
nearly normal ; if the bands be ulcerated or fixed, the voice will 
be impaired ; as a rule, however, the prognosis, under such 
circumstances, is not otherwise very grave. 



SYPHILIS OF THE LARYNX. 443 

Treatment. — Internal and local remedies deserve chief 
consideration, as upon them devolves the cure of nearly every 
case. General measures, including plenty of fresh air ; a mod- 
erate amount of exercise ; good, nourishing diet without alco- 
holics; an occasional Turkish bath; cold sponge-baths each 
morning, followed by friction with a coarse towel and horse-hair 
gloves ; friction on retiring ; absence of all excesses ; and plenty 
of sleep are important adjuncts. Local measures consist of 
sprays of iodine (gr. v to gj) and glycerin or fluid cosmolin; 
or chloride of zinc and glycerin in the same proportions. The 
iodine preparation is very useful if there be an increase of tissue, 
erosions, or actual ulcerations ; otherwise the chloride of zinc is 
better. When the ulceration is deep (tertiary), the iodine may 
be used in the strength of 15 grains to the ounce. When the 
ulcer is coated with a thick secretion this should be wiped off 
with a cotton-covered laryngeal probe before using the spray, or 
the latter may be replaced by direct applications with such a 
probe. Dr. W. R. King has relieved and cured both ulceration 
and oedema by means of the spray or vapor of guaiac, 1 drachm 
to the ounce. Severe dyspnoea may require intubation or 
tracheotomy ; if the latter, the patient should be warned that it 
may be necessary for him to wear the cannula for a long time, — 
perhaps always. The low operation is advisable, as the quasi- 
growths may pass well down the windpipe. The cannula should 
not be permanently removed until laryngoscopic examination 
reveals the absence of stenosis ; otherwise it may be necessary 
to re-insert the tube, even although the patient seem at first to 
breathe easily. The intubation tube may be left in position for 
several days ; if dyspnoea exist after its removal, it should be re- 
inserted and retained until it cause considerable irritation ; if it 
fail to relieve, tracheotomy will be demanded. Although a 
serious syphilitic oedema will usually subside, yet without intu- 
bation or tracheotomy the lungs are liable to become cedematous. 

Cicatricial contractions will be considered under " Stenosis 
of the Larynx." 



444 DISEASES OF THE NOSE AND THROAT. 

Congenital syphilis of the larynx is rather infrequent, al- 
though Dr. John N. Mackenzie believes otherwise. The affection 
is not as characteristic as is the acquired form ; for that reason 
the diagnosis must be based upon the collateral symptoms, espe- 
cially those of the pharynx, teeth, forehead, face, and eyes. 
The patient is usually attacked during the first year of life, 
although the larynx may escape until puberty ; the earlier, 
usually, the more severe the malady and the graver the prog- 
nosis. 

The symptoms are : hoarseness or aphonia ; paroxysmal 
cough with little expectoration ; often difficult respiration, some- 
times paroxysmal, amounting to laryngismus stridulus, — on the 
other hand, it may be constantly progressive and result in 
asphyxia. Deglutition is difficult or painful where the pharynx, 
epiglottis, or posterior laryngeal region is ulcerated or consider- 
ably thickened. The laryngoscopic appearances are usually 
those of chronic laryngitis, but interstitial thickening, superficial 
or deep ulcerations may occur, or perichondritis or oedema call 
for intubation or tracheotomy. 

Treatment is similar, so far as possible, to that recom- 
mended for the acquired affection. 

Therapeutics. 

Aurum mur. 3x to l'2x. — Indurated glands; general de- 
pression ; caries and necrosis of the cartilages of the larynx and 
of the bones elsewhere. 

Badiago, carbo an., carbo veg. — Tertiary syphilis. 

Kali bi. — Chiefly for the catarrhal condition so often 
present in syphilitic patients. Both internally in the 3 x to 
12 x, and as a spray of a 2-per-cent solution. 

Kali iod. — The oedema, gumma, " mucous tubercles," and 
destructive tertiary ulcerations are speedily cured, preferably in 
appreciable doses (see " Syphilis of the Pharynx "). 

Merc. cor. — Especially indicated for the ulceration, particu- 
larly if secondary and with profuse offensive secretion. It is 



STENOSIS OF THE LARYNX. 445 

of considerable value in treating the vocal defects which persist 
after the relief of the more acute secondary symptoms. 

Merc. sol. — Superficial ulcers. 

Mezereum. — Husky voice ; hoarse cough; sensation of ob- 
struction in pharynx and larynx ; blood-streaked expectoration. 

Nitric ac. — Hoarseness aggravated by speaking; stinging, 
sharp, sticking pain in the larynx ; barking cough, expectora- 
tion of offensive blood-streaked mucus. Mucous patches not 
only in the larynx, but in the mouth and pharynx as well. 

Sulph. is a remedy too much neglected, especially in cases 
of doubtful diagnosis, where it may arouse a latent syphilis that 
has produced various constitutional symptoms which resist all 
other measures. The same is true, but in a higher degree, of 
sulphur mineral waters. 

(See " Syphilis of the Nose " and " Syphilis of the Pharynx.") 

STENOSIS OF THE LARYNX. 

Etiology. — Although laryngeal stenosis may result from 
oedema, abscess, foreign bodies, tumors, pseudomembrane, etc., 
such obstructions are not to be classed under the heading 
" Stenosis of the Larynx." This title should apply only to 
purely chronic hindrances to respiration, due to the presence of 
cicatricial contractions and adhesions, the result of inflammation, 
ulceration, suppuration, or injury ; inflammatory adhesions be- 
tween the edges of the vocal bands ; to well-marked fibrous or 
fibro-cellular infiltration of the mucous and submucous tissue ; 
or to congenital membranes. Syphilis is the most frequent cause. 

Symptoms. — There are but two very characteristic indica- 
tions, namely, loss of voice and difficult respiration. For the 
former, usually but little can be done ; for the latter much may 
be accomplished by dilatation or bronchotomy. 

Treatment. — If the stenosis be severe and threaten life, the 
patient should be intubated at once, or the air-passages opened 
below the point of obstruction, when, if the respiratory difficulty 
is not very severe, it is often possible to dilate the stricture suffi- 



446 DISEASES OF THE NOSE AND THROAT. 

ciently to relieve the symptoms, thus saving the sufferer the 
frequent annoyance of wearing a tracheotomy cannula the re- 
mainder of his life. 

Dilatation of the larynx, without preliminary tracheotomy, 
may be accomplished either by Schrotter's hard-rubber bougies 
or O'Dwyer's intubation tubes. The former have long been 
tested and sometimes proved highly useful, but will, doubtless, 
disappear in favor of the intubation apparatus. When prepar- 
ing to use bougies it is usually necessary to begin with an 
English catheter ; when this can be tolerated, a very small 
bougie may be carefully introduced and left in position for a 
few seconds ; if not too irritating it may be re-inserted after a 
few minutes' rest, and then can be left a longer time, the instru- 



-A 




Fig. 116.— Schrotter's Hard-Rubber Bougie. 

d, beak to fit into glottis ; c, portion which r*sts upon the tongue ; ft, guides ; <7, curved tip for directing 
discharges from operator's face. 

ment projecting from the mouth. As soon as the larynx becomes 
tolerant of the bougies, the largest size that can be borne may 
be inserted and, perhaps, left in position ten or fifteen minutes, 
during which time the patient is obliged to keep his mouth open 
and hold a towel below his chin to catch the saliva, which 
usually flows freely. In the use of the O'Dwyer tube, the 
patient is enabled to close the mouth after the tube is well in 
position ; so that it can be left in situ several days if necessary, 
not only rendering the procedure less disagreeable, but greatly 
hastening dilatation, owing to continued pressure. It is not 
prudent to use the bougies where there is grave stenosis, but 
the intubation apparatus can be advantageously employed in 
threatening cases. 

The stenosis occasionally assumes the form of a web-like 



STENOSIS OF THE LARYNX. 



447 



membrane extending from one band to the other ; it is then 
possible to use either of the preceding methods, but a cutting 
operation often proves more satisfactory. Owing to the elas- 
ticity of the web, it is very difficult to divide it with a laryngeal 
bistoury; on that account Whistler's cutting dilator answers 
better, as it can be made to cut the web by protruding a con- 
cealed knife at the time of dilata- 
tion, but the instrument is objec- 
tionable, as it prevents breathing 
while in position. Lennox Browne 
has overcome this objection by mak- 
ing the instrument hollow. After 
the membrane is thoroughly divided, 
one of the dilating instruments may 
be inserted for a short time every 

day, with the intention of keeping the cut edges apart until 
healing has occurred ; but, unfortunately, success is rare, as 
the edges generally reunite in a short time. If divided with 
a galvano-cautery blade, this reunion may not occur. More 
recently Schrotter suggests dissecting out a central portion of 




Fig. 117.— Web-like Stenosis, 
due to Syphilis. 




Fig. 118.— Browne's Hollow Cutting Dilator. 

the web. The pain is slight and can generally be prevented by 
the use of cocaine. 

Various rapid dilators have been invented for the relief of 
laryngeal stenosis, but they are not often satisfactory, for, if they 
dilate the tissues sufficiently, they often occasion such an inflam- 
matory reaction as to increase rather than diminish the obstruc- 



us 



DISEASES OF THE NOSE AND THROAT. 



tion. They are made on the principle of forcible urethral 
dilators. 

After the performance of tracheotomy various methods of 
treatment may be adopted, namely, Schlatter's metal bougies, 
the introduction of a hard-rubber bougie, an intubation tube, a 
tupelo or rubber dilator, Stoerk's bivalve dilator introduced into 
the glottis through the fenestrum in the upper part of the trach- 
eotomy tube, or dissection of the thickened tissues. The tin 
bougies consist of a body of solid metal, to the upper end of 
which is soldered a neck for attachment to the introductory 
handle ; the upper part of the neck is perforated for the intro- 
duction of a string ; from the lower end of the body projects a 




Fig. 119.— Sciirotter's Metal Bougies. 



thin neck and head which, after removing the inner tracheotomy 
tube, are to be passed through the glottis and fenestrum in the 
outer tube. When in this position the neck is to be grasped 
and held with retention forceps. The instrument is preferably 
introduced with the aid of a laryngeal mirror, but the index 
finger of the left hand may guide the bougie into the larynx as 
in intubation. It may be left in position for some minutes at 
first ; later, an hour or more, if possible ; this should be repeated 
daily. 

In using a hard-rubber bougie or intubation tube, the 
tracheotomy tube is temporarily removed and the instrument 
inserted. The tupelo dilators are inserted through the stricture 
with the cannula in position. The rubber bag is inserted 



STENOSIS OF THE LARYNX. 449 

closed and inflated when in position. Stoerk's dilator is passed, 
from without, through the fenestrum of the outer cannula and 
the blades separated by a set-screw. If all of these methods 
fail to accomplish the desired result, and it is certain that the 
voice can never be regained, the larynx may be laid open and 
the stenotic tissue cut out. In this way dyspnoea may be 
relieved and the tracheotomy tube removed ; following this, 
there is a possibility that the vocal function may be improved 
by the formation of bands of tissue in such a way as to give a 
fair voice. Such a dissection is rarely necessary since the prac- 
tice of intubation. If the stenosis be well within the trachea, 
intubation or dissection will be indicated. 

The remedies that may be tried are cannabis sat., sulph. 
of zinc, graph., and rhus tox. 



CHAPTER XXXIIL 

Exudative Diseases. 



PRIMARY MEMBRANOUS, OR EXUDATIVE, LARYNGITIS CROUP. 

Whether membranous croup and diphtheria are one and 
the same disease does not yet appear, but recently the evidence 
favoring the unity theory is gaining ground, although the pro- 
fession is pretty evenly divided on the question. There must 
be, therefore, some good grounds for both sides of the contro- 
versy, but, so far as this work is concerned, it is not worth while 
to enter into a discussion of the subject. As the symptoms of 
primary membranous laryngitis and secondary diphtheria of the 
larynx are so similar, they will be classed together, especially 
after the stage of stenotic respiration has commenced ; and as 
the mechanical treatment is so similar in all practical respects, 
repetition will be avoided by referring the reader to " Diphtheria 
of the Pharynx and Larynx." 

Etiology. — The causes of membranous croup are essentially 
those of diphtheria, although contagion and infection are 
doubtful : nor is it apparent that decaying vegetable and animal 
matters have any particular causal influence. The causes, again, 
of membranous laryngitis are those giving rise to catarrhal con- 
ditions in general, and to catarrhal laryngitis in particular. 
Some claim that the one may gradually merge into the other. 
Heredity here, as in diphtheria, seems to act causatively, as also 
the repercussion of eczematous eruptions on the face and head. 
While some argue that one attack gives immunity to others, 
the greater number of authorities believe that it exerts little 
influence either for or against a recurrence. 

As with diphtheria, the greatest number of cases occurs in 
childhood. It is unusual during the first year, after the seventh 
to the tenth year its frequency gradually declines, and it is very 
(450) 



PRIMARY MEMBRANOUS LARYNGITIS. 451 

rare in adults. Those who are poorly nourished, fed, and cared 
for in general are more prone to membranous laryngitis, but 
too much housing and " wrapping up " are to be discouraged. 

Pathology. — Pathologically, the process consists in the 
production of a congestion, inflammation, and, later, exudation 
of a fibrinous material, usually upon the surface of the mem- 
brane. The exudation occurs in two layers ; the superficial 
consists of thickened epithelium, the cells of which have under- 
gone proliferation and mucoid degeneration ; the deep layer is 
composed of several strata of a fibrinous or membranous sub- 
stance and leucocytes. In the early stage the entire deposit 
may be pultaceous. 

When the membrane exfoliates it usually leaves a slightly 
denuded but not a bleeding or ulcerated surface, upon which 
may be engrafted an apparently true diphtheritic process, thus 
seeming to explain the occasional co-existence of the two forms 
of deposit. 

Symptoms. — Symptomatically, the disease is not always 
distinguishable, in the first stage, from other acute laryngeal con- 
ditions, but in the second there is less liability to error, and in 
the third the diagnosis is comparatively certain even without the 
aid of the laryngoscope. The premonitory stage is often so 
slight as to scarcely attract attention, although there is usually 
malaise, loss of appetite, thirst, and a catarrhal attack with 
hoarseness and cough ; which may even be croupy, but at very 
irregular and inconstant intervals, thus simulating spasmodic 
croup. The latter affection, however, usually comes like " a 
thunder-clap from a clear sky." Soon the membranous change 
shows itself in a more constant hoarseness and croupy cough, 
with difficult respiration ; at first during inspiration only, but 
later during expiration as well. This condition may be the first 
noted, or the patient may first be roused from sleep, as with the 
spasmodic affection. These symptoms are usually worse at 
night ; the amelioration may be so marked during the succeed- 
ing day. that the false hope is entertained of a speedy recovery 



452 DISEASES OF THE NOSE AND THROAT. 

which too often does not come, for by evening the patient is 
worse than during the preceding night. If the condition in- 
crease, fever is noted, the mercury registering 101° to 104° F. 
or more ; the pulse is rapid, perhaps full and bounding, and 
respiration hurried, loud, and accomplished with evident distress. 
The laryngeal symptoms then become so like those of secondary 
diphtheria of the larynx that reference must be made to that 
malady (page 215). 

The mirror may reveal a pseudodeposit on isolated points, 
or coating a large part of the lining membrane of the larynx. 
If small areas alone be covered, the ventricular and vocal bands 
often suffer first, the uncoated parts being somewhat congested. 
Failure to find membrane does not always mean its entire 
absence, as the ventricle, the subglottic region, or some equally 
hidden portion may be involved. In primary exudative laryn- 
gitis there is rarely albuminuria, sequelae are unusual, and the 
cervical glands are not often enlarged. 

Diagnosis. — The diagnosis is not always easy. Spasmodic 
croup (subacute laryngitis of children) is very similar, especially 
at the outset ; but if the condition be watched for a few hours 
it will usually be noticed that the respiratory difficulty is more 
constant in the graver disease, in which there are fever and 
malaise ; soon the dyspnoea becomes quite constant, and is 
expiratory as well as inspiratory ; but it must be remembered 
that even at a late stage of pseudomembranous laryngitis there 
may be periods of comparative immunity from dyspnoea. The 
expectoration of shreds or pieces of membrane, or the discovery 
of a deposit in the larynx, will at once establish the diagnosis. 
From acute oedema of the larynx and acute laryngitis with 
infiltration, the diagnosis is sometimes impossible without laryn- 
goscopic aid, or the appearance of membrane in the expectora- 
tion. It may generally be distinguished from secondary exuda- 
tive laryngitis by the absence of pharyngeal deposit ; but in 
some cases the latter entirely disappears before the larynx is 
attacked, or the pharyngeal affection may have been so slight as 



THERAPEUTICS OF PRIMARY MEMBRANOUS LARYNGITIS. 453 

to be overlooked, when the after-appearance of irregularities or 
even of ulcerations may be sufficient to insure the diagnosis. 
There is usually greater prostration in the secondary affection, 
more probability of heart-failure and paralysis, the latter being 
very infrequent after primary membranous laryngitis. 

Prognosis. — The outlook, in primary membranous laryn- 
gitis, is much more favorable than where the membrane extends 
from the parts above. The duration of the disease is from two or 
three days to as many weeks ; the greater number of fatal cases 
succumb about the fourth or fifth day ; when recovery occurs, 
the severe symptoms usually begin to decline on the sixth or 
seventh day ; recovery may be long delayed, but relapses are 
rare. The expulsion of the membrane, with temporary relief 
to respiration, is not a necessary proof of recovery, as the de- 
posit may form even after the dislodgment of large casts. 
Without tracheotomy or intubation from 40 to 50 per cent die, 
and one of these operations might be said to save 30 per cent of 
otherwise fatal cases. Despite numerous statistics to the contrary, 
personal experience, coupled with that of a number of friends 
of both schools of practice, leads me to say that, even with opera- 
tion, recovery from secondary laryngeal diphtheria is infrequent. 

Treatment. — The local treatment is practically the same as 
that required for secondary membranous laryngitis ; stimula- 
tion is rarely demanded, neither is it so necessary to keep the 
patient quiet so long after apparent recovery. The remedies 
employed are similar, but not identical, in the two varieties ; 
consequently, they will be considered in both connections. The 
prophylactic treatment consists in eradicating those conditions 
which have been noted as causing the disease and in avoiding 
"cold-catching" as much as possible. Eucalyptol, 10 per cent 
in fluid albolene, has had much praise. 

Therapeutics. 
Acetic ac. — Locally, as an inhalation or a weak spray, as 
well as internally. Hissing, rattling, labored breathing. Some 
consider this remedy almost a specific. 



454 DISEASES OF THE NOSE AND THROAT. 

Aeon. — As with the spasmodic variety, if due to dry, cold, 
northwest winds, aeon, often acts well if given early, before the 
membrane has formed, and where the particular aconite fever is 
present ; hard, dry, barking cough, and loud expiration. 

Antim. tart, is of undoubted value after the membrane is 
loosened, but the patient has scarcely strength to expel it ; the 
face is cold, bluish, covered with cold perspiration ; rattling of 
mucus and membrane. 

Antipyrin. — A woman, 60 years of age, was cured by Dr. W. 
M. Decker, after failure of aeon, and spongia. The use of 
antipyrin was followed by the expulsion of " a membranous 
cast from the trachea." (N. A. Jour. Homoeop., March, 1889.) 

Bell. — Croupy, barking cough ; sawing, whistling respira- 
tion ; very restless, midnight aggravations ; bright-red throat 
and tonsils. This remedy cured one case in which I saw mem- 
brane in the larynx, and for which operation seemed to offer 
the only hope. 

Cham, is Charge's greatest remedy ; when the general char- 
acteristics of the drug were present, he has not lost a case. 

Iodine. — Wheezing and sawing respiration ; dry, barking- 
cough, or, later, when the cough is muffled and indistinct with 
intense dyspnoea and torpor from membranous obstruction ; pain 
in the larynx, at which the child grasps ; the face pale and cold, 
and the voice deep, hoarse, and gruff. 

Kali bi. has a great reputation in the cure of membranous 
laryngitis, either primary or secondary ; and justly so, if the ex- 
pectoration be stringy, occasionally pseudomembranous, and 
when the air gives rise to a peculiar metallic sound as it passes 
through the larynx. Hoarseness or aphonia and moderate 
dyspnoea. There is a tendency for the membrane to extend to 
the trachea and bronchi (kaolin). Aggravation about 3 A.M. 

Kali mur. " is the principal remedy for the membranous 
exudation alternately with ferrum. phos." (Boericke and Dewey.) 

Liquor calcis chlorinati. — " This remedy seems to exert its 
influence principally, if not entirely, upon diphtheritic membrane 



TRAUMATIC CROUP. 4:55 

in the larynx and trachea, loosening and facilitating its expec- 
toration." (Dr. O. S. Haines.) 

Sang. can. — Pseudomembrane in the larynx, with a dry, 
burning, swelled feeling in the larynx and pharynx, and croupy 
" wheezing-whistling " cough; threatened suffocation. 

TRAUMATIC CROUP. 

Etiology. — This affection needs but brief mention. It gen- 
erally occurs in children, is usually occasioned by inhalation or 
deglutition of irritant poisons, scalding water or steam, flames, 
chemicals, and caustics. The latter include ammonia, galvano- 
cautery, etc. 

Symptoms. — The symptoms differ but little from primary 
croup, although there is greater pain in the larynx, and usually 
much more pharyngeal soreness. The laryngoscopic appearances 
are similar to those in primary membranous laryngitis, but there 
is often greater intensity of the inflammatory process and oedema 
is not infrequent, especially in adults. 

Prognosis. — The prognosis is exceedingly grave in very 
young children ; the older the patient, the better it becomes. 
Much depends upon the extent and situation of the lesion. 

Treatment. — Emollient sprays, chiefly the various petro- 
leum preparations, are to be used early. Cold external applica- 
tions are of utility. Scarification, intubation, or tracheotomy 
may be required. 

The internal remedies are of great value, especially aeon., 
apis, bell., and sang. can. 



CHAPTER XXXIV. 

Laryngeal Tumors. 

Laryngeal growths may be either benign or malignant. 
Fortunately, the benign far outnumber those of the more deadly 
variety. Whereas a few years ago it was believed that the lines 
of demarcation between malignant and benign neoplasms were 
sharply cut, it is now known that these lines are sometimes but 
imperfectly mapped out, and so-called benign tumors sometimes 
undergo malignant degeneration. It has been proved, however, 
that these tumors rarely, if ever, undergo this metamorphosis as 
the result of instrumental irritation, as once taught ; finally, both 
forms of new growths may co-exist. 

The benign tumors found here are papillomata, fibromata, 
fibro-cellulomata, myxomata, angeiomata, lipomata, adenomata, 
and cystic tumors; the malign, sarcomata, epitheliomata, and 
medullary carcinomata. 

BENIGN NEOPLASMS. 

Etiology. — The most frequent cause of benign tumors seems 
to be a laryngeal catarrh, in which hyperemia enters to a promi 
nent degree ; to this universal cause may be added post-nasal 
adenoids, irritants, use of the voice during its t; change " at 
puberty, imperfect voice production, and the various dyscrasiae, 
particularly phthisis and syphilis. Often no cause can be found. 
It is always wise to look for a tuberculous condition of the lungs 
or of the neoplasm in every case of laryngeal growth. 

These tumors may occur at any age, but are more frequent 
in middle life ; males are oftener attacked owing to their 
greater catarrhal proclivities, the greater irritation arising from 
their occupations, and the greater strain often brought upon the 
vocal organs. 
(456) 



LARYNGEAL PAPILLOMATA. 457 

Pathologically, laryngeal growths are not different from 
the same class of tumors when occurring elsewhere on mucous 
surfaces. 

Papillomata (warts) are the most frequent of all the varie- 
ties of laryngeal tumors, and are considered most characteristi- 
cally benign ; but it cannot be denied that they do sometimes 
recur after removal, even though, apparently, totally extirpated. 

Symptoms. — The symptoms of papillomata are rather 
meagre and are rarely sufficient to insure the diagnosis without 
the aid of the laryngoscope. If the tumor be small there may 
be no symptoms, but, if pedunculated, even a small growth may, 
by change of position, cause irritation, 
dry cough, and slight expectoration, 
which may be bloody or contain por- 
tions of the growth ; should the papil- 
loma fall between the vocal bands, the 
voice will be momentarily impaired or 
even lost ; sometimes the tumor may 
divide the vibrating rima glottidis into 

. . . -, ill • Fig. 120.— Papillomata Fol- 

two portions, when a double voice lowing typhoid fever. (See 

author's report of case in Hah- 
(diphtllOnia) may be produced. These nemannian Monthly, February, 

vocal changes occur in several forms of 

tumors, in ulceration of the vocal bands, and in nervo-muscular 

spasm of the tensors of the bands. 

When large, the tumor may so fill the glottic space as to 
cause marked or even fatal dyspnoea, or by its position impair 
the action of the adductor muscles. Deglutition may be affected 
if the growth be situated upon the epiglottis or in one of the 
valleculse. Pain is unusual, but the sensation of a foreign body 
is frequent. There is rarely any external manifestation of the 
tumor, and the general system only suffers when there is diffi- 
cult deglutition or impaired respiration. 

Laryngoscopically, papillomatous growths resemble a wart, 
cauliflower, raspberry, or mulberry ; irregular in outline, granular 




458 



DISEASES OF THE NOSE AND THROAT. 



and either gray or pinkish in color, they usually spring from the 
vocal bands and vary in size from a mustard-seed to an English 
walnut. In some instances they completely fill the laryngeal 
cavity and invade the parts above or below. Although nearly 
always sessile, laryngeal papillomata are sometimes peduncu- 
lated. It has become customary to speak of a papillomatous 
growth, but in reality it is generally more correct to speak of a 
mass of these growths, which usually starts as a single point, 
often as a spot of granulation tissue. When touched with a 
probe the neoplasm will be found rather soft, insensitive, and, 
on rather firm pressure, frequently bleeds. 

Treatment. — Medicines internally and locally applied cure 
many cases, but mechanical interference is frequently necessary. 
The instruments chiefly used are forceps, scissors, knives, snares, 




Fig. 121.— Papillomata in a Boy, Re- 
moved BY ENDOLARYNGEAL METHOD, 

Seven Years Following Tracheotomy. 
(See Hahnemannian Monthly, Nov., 1888.) 




Fig. 122.— Papillomata in an Army 
Officer, mt. 54. 



guillotines, the galvano-cautery, and sponge probang. The 
best applications are : tannic acid, gr. xx, to glycerin, gj ; 
iodine, gr. xv ; and thuja tincture. 

Therapeutics. 

" Caust. has seemed to benefit two cases of laryngeal papil- 
lomata of small size, where the subjective voice symptoms were 
present ; and one case of papilloma disappeared under arnica 
where use of voice produced aching in the throat and chest." 
(Malcolm Leal.) 

Sang, nit., especially when associated with follicular 
pharyngitis and adenoid vegetations. 

Thuja is, perhaps, the nearest similar, and has cured 
numerous cases. Locally and internally. 

Compare ars., calc. phos., psor., and rhus tox. 



FIBRO-CELLULAR TUMORS OF THE LARYNX. 459 

Fibromata (fibrous tumors) are less frequent than papillo- 
mata. The former consist of white fibrous tissue. They are 
pedunculated, smooth in outline, pinkish or red in color, quite 
hard and resilient to the touch, and in size comparable to the 
papillomata. These neoplasms do not bleed easily, are somewhat 
sensitive, but, like the warty growths, generally spring from the 
vocal bands. According to the present state of clinical ex- 
perience, remedies have less influence than upon the former 
variety. 

Treatment. — Strong forceps, the knife, and galvano-cautery 
will be found the best instruments for removing these growths. 
Instances are not wanting in which bronchotomy has been imper- 
atively demanded, for the relief of dyspnoea, both in fibrous and 
warty growths of the larynx ; in at least one such case reported 



\f 



Fig. 123.— Papillomata in an Inveterate Drinker of Alcoholics. 

by J. F. Baldwin (Neio York Med. Record), the operation was 
averted and the tumor absorbed by intubation. After the pa- 
tient has sufficiently recovered from the effects of a tracheotomy, 
it is best to attempt removal of the tumor by the endo-laryngeal 
method ; if this absolutely fail, the larynx may be divided and 
the tumor extracted. The clangers of this operation are pneu- 
monia and, more frequently, a permanent hoarseness or loss of 
voice. 

Compare bell., calc. phos., conium, and silica. 

Fibro-cellular tumors (true polypi or soft fibromata) are 
rarer than either of the preceding varieties. They are usually 
quite small, smooth, rather hard, red, semi-transparent, sessile, 



460 DISEASES OF THE NOSE AND THROAT. 

and spring from the vocal bands. The same treatment is to be 
used here as in the preceding class, although tracheotomy is 
rarely indicated. Dr. Charles Ozanam reports the cure of a 
polypus, which was " red, with a sessile base, and formed a 
projection of three millimetres, with about the same diameter," 
by the use of berberis. 

Myxomata (mucous tumors), though bearing some resem- 
blance to fibromata, are of a deeper pink, more translucent, and 
much softer to the touch ; they are smooth and glisten slightly. 
A probe may easily be pressed into their substance. They bleed 
readily and are easily broken down with forceps. The micro- 
scope may alone differentiate them from cysts. Their treatment 






Fig. 124.— Polypus of Right Vocal Band. 

is not unlike that to be employed in the cure of papillomata, 
which they most nearly resemble in consistence. 

Adenomata (glandular tumors) are very rare. They gen- 
erally spring from the epiglottis, and present a solid appearance 
with a mammillated surface. 

Compare badiago, bry., conium, iod., lap. alb., phytol., 
silica, and sulpli. 

Angeiomata (vascular tumors) are recognized by their gland- 
ular outline and dark, almost black, color, especially after phona- 
tion. In appearance they somewhat resemble a bunch of black 
currants, and bleed easily and profusely. They are best treated 
by remedies internally or locally applied, but may safely be de- 
stroyed with the galvano-cautery. 



ENCHONDROMATA OF THE LARYNX. 461 

Carbo veg. should be a good remedy for such tumors, as 
also aesch., ham., iod., and mix vom. 

Lipomata (fatty tumors) are the rarest of the laryngeal 
tumors, so far as reported. They have a membranous pedicle, 
and are smooth, rounded, yellowish white, and slightly resilient 
to contact of the probe. 

Compare agar., baryta, calc, crocus, graph., lap. alb., 
phos., and phytol. 

Cystic tumors (cysts) are not so rare as once supposed. 
They are due to retention of the secretions of the mucous glands 
and the dilatation either of the cul-de-sac or of the excretory 
ducts. Their favorite seats are the epiglottis and ventricular 
bands. They are smooth, shining, slightly transparent, and 
easily indented if filled with a serous, purulent, or bloody fluid, 
but are quite hard if caseous in consistence. They usually have 
a rounded, broad, pale attachment, and there is generally an 
areola of congestion extending some distance on to the surround- 

Cysts on the vocal bands are rare and cannot be distin- 
guished from them in color ; when in this location, they affect 
the voice materially. In some instances they repeatedly burst 
and refill, with consequent temporary vocal improvement, but 
recurrence is not usual after rupture. It is sometimes possible 
to remove them by internal remedies, but it is better to punc- 
ture them with a guarded laryngeal knife; should the contents 
be too caseous to flow out after incision, a part of the sac-wall 
had better be torn away with cutting-forceps, and the contents 
curetted or sac cauterized. Should the cyst be very large, it 
may be found necessary to do a preliminary tracheotomy, after 
which a tampon cannula should be inserted, when the cyst may 
be opened with safety. 

Enchondromata (cartilaginous tumors) arc exceedingly rare; 
they are very hard, smooth, and of the color of the mucous 



462 DISEASES OF THE NOSE AND THROAT. 

membrane. They may necessitate tracheotomy, although chro- 
mic acid will, at times, destroy them or cause their absorption. 

Chorditis Tuberosa. — These little vocal nodules are 
usually found in singers and public voice-users, perhaps due to 
faulty voice-use. Usually one band is alone affected, but the 
second may follow late. It is my experience that these patients 
furnish a rheumatic or gouty history, either family or personal, 
and that this diathesis has some causative influence. The sing- 
ing voice is always affected. Although this pathological process 
may be secondary to a chronic catarrhal laryngitis, I believe it 
independent of such a cause. The presence of these nodes 
causes muscular fatigue, especially of the adductors. 

Rice says (N. Y. Med. Jour., January 24, 1891): "These 
nodular enlargements are produced by the friction of the free 
edge of one band against that of the other where the voice is 
used a great deal, and where the tension of the bands is un- 
evenly controlled because of a faulty method of using the 
laryngeal muscles, just as the outer layers of the skin of the 
foot are hypertrophied by the friction of an ill-fitting shoe." 
Chorditis tuberosa may occur upon one or both bands ; when 
the latter, the nodules are directly opposite. Their usual posi- 
tion is at the junction of the anterior and middle thirds of the 
bands, and on the free margin. 

Thyroid gland-tissue has occasionally been found in extir- 
pated laryngeal growths, and Eppinger and Semon have de- 
scribed tumors of the larynx as occurring in lymphadenoma, or 
Hodgkin's disease. 

Pachydermia verrucosa laryngis has been carefully con- 
sidered by Virchow, Jiirgens, Massei, and others, and chiefly 
brought to notice in connection with the historic case of Em- 
peror Frederick III. It is infrequent. In this condition the 
squamous epithelial lining of the inter-arytenoid space and the 



BENIGN NEOPLASMS OF THE LAEYNX. 463 

posterior ends of the vocal bands undergo a change which con- 
sists of an increase of epithelium. Pachydermia shows itself 
in two forms, one of which, the circumscribed (warty pachy- 
derm), is characterized by its ever-increasing dermoid charac- 
ter and its resemblance to papillomata ; the other embraces 
changes in the mucous membrane proper, with a diffuse swelling. 
The latter usually appears especially near the vocal proc- 
esses of the arytenoid cartilages. When at this point, a swelling- 
may occur, usually directed downward and forward, with its 
anterior extremity under the vocal muscle;, within this swelling 
is a superficial groove, which Virchow first ascribed to irritation 
of old cicatrices. " This change is never found alone, but is 
associated with a diffuse disease which extends over the entire 
vocal band. The whole surface is in a condition of epithelial 
proliferation. The thickened wall surrounding the depression 
is found to be infiltrated with papillae, covered with rich layers 
of epithelium. . . . There is also usually a continuation 
of the disease into the inter-arytenoidal space, where may some- 
times be seen in great extent, even with the unaided eye, thick 
outgrowths and folds, with epidermoidal coverings which present 
a very striking appearance in their strength and extent." {Ann. 
Univ. Med. Sci., 1888.) Pachydermia is essentially a disease of 
drunkards, is usually bilateral, and of slow advance. Its symp- 
toms are similar to those of chronic laryngeal catarrh. 

General Symptoms of Benign Growths.- — Some benign 
tumors may cause difficult deglutition, when the growth is quite 
large or situated on the epiglottis or arytenoid cartilages. The 
voice is often characteristic in that it may be good at one minute 
and gone at the next, owing to tilting of the neoplasm. It is 
suppressed when a large growth is situated upon the vocal 
bands, preventing their approximation or vibration. Dyspnoea 
is present when the tumor partially closes the glottis, and when 
a pedunculated tumor momentarily changes position and falls 
into the glottic space. Pain rarely accompanies benign growths, 



46-i DISEASES OF THE NOSE AND THROAT. 

but cough is often a constant and exceedingly annoying symp 
torn. Expectoration is inconstant. 

The laryngoscopic diagnosis is rarely a difficult matter ; 
the only condition likely to be mistaken for a tumor is eversion 
of the laryngeal ventricle. In this the fold of membrane can 
be temporarily replaced by a bent probe, making the diagnosis 
easy, although the fold of tissue may sometimes necessitate a 
cutting or cauterizing operation for its permanent relief, owing 
to its hindrance to vocalization. A small tumor may be hidden 
from view if the ventricular band be much enlarged. 

Prognosis. — The prognosis is usually good so far as life is 
concerned ; the only dangers are the remote possibility of malig- 
nant degeneration and the immediate one of suffocation. 

Treatment. — One word of caution is here needed, namely, 
Ttnv instrumentation within the larynx, unless under full illumi- 
nation, may not only injure the healthy tissues of the larynx, 
but originate a fatal inflammation of that organ. The mere 
presence of a tumor in the larynx is not sufficient warrant for 
its removal. Unless time be limited a small growth that gives 
rise to little annoyance should be first treated with remedies 
and watched, but if it considerably interfere with vocalization 
and respiration it is rarely well to delay operative procedures. 
Tumors, especially if recent, may disappear spontaneously by 
t; slow atrophy and resorption " (Virchow) ; some will follow 
a more rapid decline by relief or cure of the congestion ; others 
may be dislodged during cough, etc. ; and a fair proportion will 
disappear rapidly under the influence of appropriate internal 
medication. 

The preparation of the patient for the operation and the 
methods of procedure are of considerable moment. Formerly 
the patient was either drilled to the use of the instruments, or 
locally anaesthetized with applications of chloroform and mor- 
phine. The latter method has become obsolete since the intro- 
duction of cocaine bydrochlorate. Drilling is less practiced, but, 
nevertheless, is often the best method, especially when aided by 



TREATMENT OF BENIGN" NEOPLASMS OF THE LARYNX. 465 

cocaine. It is practiced by daily instrumentation of the pharynx 
and larynx, first with probes and later with the instrument to 
be used in the removal of the growth. When the larynx be- 
comes thoroughly tolerant of the instrument, — always by the 
aid of the laryngoscope, — the tumor is grasped or encircled 
and removed ; if possible, in one mass, or, if necessary, in frag- 
ments. Haemorrhage is usually insignificant. Should the first 
attempt fail, the instrument may be re-introduced as soon as 
the larynx recovers from the spasm or irritation which some- 
times follows. It is not well to repeat the attempt more than a 
few times at each sitting, lest the patient become exhausted or 




Fig. 125.— Mackenzie's Anteroposterior Forceps. 

severe inflammation, oedema, or perichondritis be induced. 
These results can be avoided if no attempts be made to remove 
the tumor without thorough laryngoscopic illumination. Al- 
though some operators, notably Stoerk, grasp the growth even 
when unable to see it, calling to aid the memory of its exact 
location, such a procedure is not advisable, except in the hands 
of such experts. Growths are sometimes removed at "the first 
visit, the parts being cocainized by a 4- to 20-per-cent aqueous 
solution, applied directly to the larynx three or four times at 
five-minute intervals. Should this fail to answer, a whiff of 
chloroform will aid the local anaesthesia without causing general 
insensibility. 



466 



DISEASES OF THE NOSE AND THROAT. 



The operator takes the mirror in his left hand and, under 
good illumination, introduces the instrument with his right, 
directing: its movements with the aid of reflection, at the same 




£.A,rAf>HALL.pWLA. 



Fig. 126.— Mackenzie's Lateral Forceps. 



time remembering that an anterior motion of the instrument 
gives a reflected appearance of a posterior " pass." When in 
close relationship to the growth the blades of the forceps, pre- 
viously closed, are to be separated ; the tumor is to be firmly 




Fig. 127.— Schrottkr's Universal Handle with Various Tips 



grasped and a portion or all removed by gentle traction. If a 
snare be used, the loop must be passed around the growth and, 
when in position, tightened and withdrawn. Mackenzie's 



TREATMENT OF BENIGN NEOPLASMS OF THE LARYNX. 467 

guarded wheel- ecraseur may be employed in the same manner. 
A curette can be used for the removal of tumors situated upon 
the upper surface of the vocal bands. If the growth be small* 
pedunculated, and situated on the free edge of the vocal band,, 
it can sometimes be brushed off by passing a Voltolini sponge 
probang through the glottis once or twice. 

In severe conditions, where possible, a rubber or metal in- 
tubation tube should be inserted, for the purpose of relieving 
dyspnoea and of causing pressure-absorption of part or all of 
the tumor. If this fail, a preliminary tracheotomy may be de- 
manded. As soon as the fever and inflammation subside, further 




Fig. 12S.— Author's Modification of Schrottee's Laryngeal Tube- Forceps. 

By means of this modification a collar is forced over the joint of the blades, closing the tips on a level with th« 
opened tips, thus avoiding the necessity of drawing the closing jaws away from the neoplasm. 



efforts should be made to remove the growth through the 
natural passages (endo-laryngeal method). Should this not suc- 
ceed, the tracheotomy cannula is to be removed, and efforts 
made to extirpate the growth with forceps or snare through the 
opening in the trachea. If again unsuccessful, the crico-thyroid 
membrane should be divided and the efforts repeated, or the 
thyroid cartilage split directly in the median line (laryngotomy 
or thyrotomy). The thyroid plates are to be separated and 
every part of the tumor removed with forceps, scissors, snare, 
knife, or cautery, according to indications. The cartilage is to 
be re-united as accurately as possible ; even then the voice is 
often impaired. 



468 ' DISEASES OF THE NOSE AND THROAT. 

MALIGNANT TUMORS. 

Malignant growths of the larynx are rare before the fortieth 
year, but Rehn records a case occurring in a child three years 
of age; they are more frequent in men than in women. 
Although occasionally primary, laryngeal cancers are usually 
secondary, and not infrequently appear as the result of exten- 
sion from neighboring structures, particularly from the pharynx, 
when they are usually epitheliomatous. 

Epitheliomata are the most frequent ; encephaloid (medul- 
lary) and scirrhous much less common. Hereditary influence, 
apparently, plays an unimportant role in the production of cancer, 
but there is evidently an underlying proclivity in all who are 
attacked with malignant growths, which may be akin to 
heredity. There seems little doubt that the presence of irri- 
tants (tobacco, alcohol, etc.) aid in developing primary growths. 

Epithelioma. — If the disease be primary, hoarseness is 
usually the first symptom to appear ; it may be accompanied or 
speedily followed by pain. Laryngoscopic examination renders 
it quite evident that some severe malady is present, on account 
of the swelling and often marked redness. When a secondary 
growth extends from the pharynx or oesophagus, deglutition 
will be difficult and painful ; and sharp, lancinating pain fre- 
quently extends to the ears, owing to the neoplastic irritation of 
sensitive fibres of the superior laryngeal nerve irradiating, as 
von Ziemssen suggests, upon the auricular branch of the pneu- 
mogastric. Pain is less severe when the disease is limited to 
the interior of the larynx (intrinsic) than when it attacks its 
outer portion and neighboring structures (extrinsic). If the 
tumor extend from the thyroid gland, difficult respiration, pain, 
and hoarseness may first appear. When thoroughly established, 
cough is often a complicating condition, and respiratory diffi- 
culty is great when the breathing space is much encroached upon 
by the growth, loose cartilage, oedema, or posterior crico- 
arytenoid paralysis. Ulceration is, later, added to the other 



EPITHELIOMA OF THE LARYNX. 469 

changes ; then it is that the true suffering of the patient begins 
and too often terminates only when death asserts its claim. 
After the onset of ulceration there is usually a very offensive, 
often tenacious and bloody discharge, which may contain parti- 
cles of broken-down tissue ; therefore, when the diagnosis is 
uncertain, the sputum should be submitted to microscopic tests. 
Painful, difficult, or impossible deglutition occurs only when the 
ulceration attacks the epiglottis, arytenoid region, or pharyngeal 
wall. Pain is usually constant, but is occasionally absent 
throughout. Cough is annoying and often very painful, 
although not usually constant ; it depends upon the sensation 
of a foreign body in the larynx, compression of the trachea or a 
nerve, or irritation of the latter. The voice is very rough, 
hoarse, gruff, or suppressed, depending upon the position of the 
ulceration, the involvement of the muscles, the degree of infil- 
tration, the amount of nerve-pressure, and the absence or pres- 
ence of cartilaginous involvement. The picture is often in- 
complete, however, without the cachexia; the weakness; the loss 
of sleep ; the often insatiable hunger, which the patient cannot 
appease ; and the burning thirst, which no fluid can fully quench. 
It is not unusual for the cervical, tracheal, and bronchial glands 
to be implicated. 

The primary laryngoscopic appearances are often incom- 
plete. When one band is sluggish in action and congested with 
a pale or pink nodule, malignant tumor should be suspected. The 
immobility is probably due to infiltration, — a feature of malig- 
nancy. When one vocal ligament is concealed from end to end 
by a papillary growth, cancer is probable, especially if the gran- 
ules are quite large and in an elderly person. Von Ziemssen 
has noted hoarseness or aphonia years before the tumor appeared. 
The nodule or swelling soon becomes well marked and some- 
times circumscribed. The surface is irregularly nodular and of 
a purplish color, unless it attack the vocal bands, when it is 
very pale or slightly pink. The intrinsic variety generally 
originates in the lateral laryngeal wall ; but when the cancer 



470 DISEASES OF THE NOSE AND THROAT. 

proceeds from the pharynx, the first evidences of congestion and 
thickening usually begin on the free edge of the epiglottis and 
extend to the interior of the larynx, by the way of the ary- 
epiglottic folds. Ulceration soon follows upon the advancing 
congestion and thickening ; even at a very early stage the larynx 
is displaced, thus differing from syphilis and phthisis. When 
ulceration occurs the condition becomes very characteristic ; veg- 
etations often appear around the edges of the ulcer, and, break- 
ing down, add to the general destruction. The ulcer is very 
ragged, inflamed, and below the surface of the elevated tumor. 
As the disease progresses the cancerous mass may fill the greater 
part of the laryngeal cavity and invade the surrounding struc- 
tures. 

Diagnosis. — The diagnosis is not usually difficult after the 
appearance of ulceration, but in the earlier stages it is not 
always possible to determine the exact condition. The chief 
differential points have been noted under " Syphilis of the 
Larynx." When an apparently papillomatous growth is sur- 
rounded by an inflamed and infiltrated " reddened zone," epi- 
thelioma should be suspected ; and any growth springing from 
the ventricle should arouse anxiety, eversion of this sac ex- 
cluded. Transillumination usually reveals a dull, cloudy area 
circumscribing the growth and corresponding to the amount of 
collateral inflammation ; such a shadow-line is not seen in 
benign growths. If, after removal of a part or all of the growth, 
recurrence take place without previous cicatrization, malignancy 
is the rule ; but if after that result, benignity is almost certain. 

Sarcoma, when intrinsic, generally starts as a firm, smooth, 
rather soft, well-defined, and sessile, unilateral tumor. It usually 
arises from a vocal or ventricular band or ventricle, although 
the entire larynx may be invaded or the growth appear as a 
submucous, cauliflower-like infiltration or tumefaction. It is 
somewhat redder than epithelioma, more vascular, may undergo 
earlier ulceration, and is more prone to bleed profusely ; if ex- 



MALIGNANT TUMORS OF THE LARYNX. 471 

trinsic it originates in the pharynx. The subjective symptoms 
differ but little from those noted under " Epithelioma." Laryn- 
goscopically, the diseases are well defined. While in both 
there is great displacement of the larynx and surrounding tis- 
sues, epithelioma is pale, nodular, and very slightly vascular ; 
sarcoma is smooth, brighter in color, and extremely vascular. 
A sarcoma occasionally resembles either a papilloma or a fibroma 
in appearance. 

General Symptoms of Malignant Growths. — In malignant 
diseases of the larynx there is nearly always some glandular 
involvement ascertainable by external palpation; the excep- 
tional cases occur in intrinsic sarcomatous growths ; even then 
glandular enlargements are sometimes detected post-mortem. 

It was formerly taught that the lymphatic supply of the 
larynx was isolated, and on that account malignant tumors of 
the larynx were rarely due to secondary deposit ; but Sappey's 
researches have demonstrated the fallacy of this teaching. It 
has been proved clinically, as well as by means of post-mortem 
injection, that there is a direct communication between the lym- 
phatics of the larynx and those of the trachea and bronchi, 
and it is now known that distant secondary growths are not so 
rare as was formerly supposed. Enlargement of the glands in 
the course of the recurrent laryngeal nerves may be accountable 
for paralysis of the laryngeal muscles supplied by these nerves. 
It has now become well established that the early symptoms 
of cancer of the larynx may closely simulate aneurism of the 
mediastinal region, owing to cancerous enlargement of the 
bronchial lymphatic glands. 

External palpation often reveals the enlargement within, 
and in rare cases there are external evidences of the internal 
ulceration. Although the general health is nearly always affected 
and cachexia is present, the flesh may be up to the standard ; 
and in intrinsic malignant growths the patient may present no 
external evidence, although post-mortem examination reveals 



472 DISEASES OF THE NOSE AND THROAT. 

the malignant anaemic condition of the tissues. In severe ulcer- 
ation loss of flesh is often chiefly due to dysphagia. 

Prognosis. — The prognosis is always unfavorable, although 
some cases recover spontaneously, or as the result of remedies 
or surgical interference. The usual duration of life is about 
two years. Small-celled sarcomata are the least malignant; 
spindle-celled and alveolar sarcomata more so; and epitheliomata, 
after ulceration begins, most malignant. The prognosis of 
keratoid (cornified) carcinomata, however, is better than that 
of the soft variety. In all forms the prognosis is better when 
the disease is confined within the larynx proper. Death is 
usually due, in primary cases, to marasmus, asphyxia, or 
haemorrhage ; in secondary, to pneumonia, deposit in more vital 
organs, or to ulcerative perforation of the oesophagus. 

Treatment — In the early stages internal remedies will do 
much to improve the patient's condition and prevent the progress 
of the growth ; later, it may be necessary to add cleansing sprays. 
If the pain be very severe and remedies fail, soothing applica- 
tions may relieve, but in the worst cases anodines may be 
necessary. When alarming dyspnoea exists, tracheotomy should 
not be withheld. If it be impossible to give the proper amount 
of nourishment either by mouth or rectum, the oesophageal feed- 
ing-tube should be employed, if practicable; otherwise gastros- 
tomy may be performed. 

Although some physicians consider palliatives a confession 
of ignorance of the proper application of the homoeopathic 
remedy, that confession is sometimes necessary in this usually 
incurable and intensely painful disease. The best local palliato- 
curatives are calendula, cannabis sat., Hydrastis, and thuja ; and 
the chief palliatives are cocaine, morphine, iodoform, iodol, and 
aristol ; external heat and chloroform often greatly relieve. 
Where there is much earache, hot water, calendula (30 per cent), 
bell. 3 x (aqueous solution), or plantain-oil may be dropped into 
the external auditory canal with good effect. Internal remedies 
very generally give decided relief and often dull the pain at 



MALIGNANT TUMORS OF THE LARYNX. 473 

once. They should always be prescribed with care and given 
a fair trial before resorting to palliatives. 

Cauterization of laryngeal cancers is to be deprecated, with 
one exception : if the free portion of the epiglottis alone be in- 
vaded, the growth may be totally destroyed by the galvano- 
cautery point ; caustics are never advisable. Tracheotomy may 
relieve dyspnoea and give respiratory rest to the larynx, check- 
ing the rapid progress of the disease ; thus the patient may be 
rendered more comfortable and life prolonged several months at 
least, unless some bronchial, lung, or blood affection complicate 
the operation, which, however, is unusual. After repeated con- 
trasts with non-tracheotomized patients, Fauvel considers trache- 
otomy useful as well as often necessary. For the fulfillment 
of the objects stated, a low operation is to be advised, else the 
growth may extend to the cannula and obstruct its outlet. 
Endo-laryngeal removal is worse than useless unless complete, 
as surface denudation and the consequent irritation only increase 
the suffering and the progress of the cancer ; the complete 
operation is rarely possible unless the tumor be somewhat 
pedunculated. 

The patient should be placed on a nutritious but non- 
stimulating and easily assimilable diet, with favorable hygienic 
conditions ; irritating dust, tobacco, and smoke should be 
avoided, and, when possible, a residence secured where the 
air is pure and fresh. When odonphagia becomes severe and 
remedies fail to relieve, small pieces of ice may be held in the 
mouth, and cocaine (1 per cent) or calendula (20 per cent) 
sprayed upon the throat half an hour before eating ; these 
failing, morphine (gr. J) with starch (gr. iij) may be used as an 
insufflation. Occasionally, the oesophageal tube may be passed 
and peptonized food introduced into the stomach ; but, should 
any undue resistance be noted during the introduction of the 
tube, the attempt should be discontinued ; otherwise perforation 
and severe haemorrhage may follow. Rectal alimentation is 
frequently necessary. 



474 DISEASES OF THE NOSE AND THROAT. 

The question of complete or partial extirpation must claim 
a few words. At present there is some doubt as to the strict 
propriety of the operation ; it is at all times a very unsatisfactory 
procedure, and one that often seems more likely to hasten the 
fatal termination than add to the length of the sufferer's life. 
Patients who are in a fairly comfortable condition are not in- 
frequently subjected to the operation, the shock of which, or a 
secondary pneumonia, may prove fatal ; if recovery ensue it is 
usually for a short period only, on account of secondary mani- 
festations either in the same or in some other part of the body. 
On the other hand, it must not be forgotten that cases have 
survived the operation and lived for years, speaking with a 
more or less satisfactory voice, with or without an artificial 
larynx. In place of the latter appliance, Mr. Charter Symons, 
of London, has succeeded in establishing a low, distinct, but 
gruff voice in a case of total extirpation for epithelioma by 
passing, through the upper wall of the cannula, a curved tube, 
which reached to the base of the epiglottis and conducted air 
when the cannula was closed with the finger or a pea-valve. 
In this case the vibrating structures appeared to be the mucous 
membrane of the pharynx running back from the epiglottis. 

Even though the patient seem well for a time, he usually 
dies (from recurrence) sooner than he would most likely have 
done had tracheotomy been the only operation. To this state- 
ment a few brilliant cures form the only contrast, while some 
operators are classing tracheotomized cancerous patients among 
the ofttimes curable. It will, therefore, require some years to 
determine the exact standard for laryngectomy ; until that time 
the operation must be looked upon as one of the possibilities, 
with reference to which it is best to be conservative. 

A few words with reference to partial extirpation will 
suffice. It is a much safer operation than total extirpation, but 
it is not always possible to remove all of the cancerous tissue, 
hence not universally applicable. It is not indicated when the 
cervical glands are enlarged. In partial extirpation there is 
less danger of pneumonia, and the risk of exposing the pneumo- 



THERAPEUTICS OF MALIGNANT TUMORS OF THE LARYNX. 475 

gastric nerve is only half as great. Occasionally, good results 
have been reported from division of the larynx followed by the 
removal of the diseased soft parts only. 

A great advancement, in operative technique, seems to have 
followed the employment of Eugene Harm's sponge-tampon 
cannula rather than the India-rubber one of Trendelenburg, 
formerly employed. Hahn's method of operation is less liable 
to be followed by shock, pneumonia, and early death, while 
deglutition is little impaired ; an artificial larynx is not a neces- 
sity, and it is usually possible to remove the tracheotomy tube 
after a few days. Tauber {Deutsche Med. Zeit., July 20, 1891) 
has tabulated 163 cases of extirpation; of these, 67, or 41.1 
per cent, died as the direct result of the operation ; 13, or 7.9 per 
cent, were cured — that is, were without recurrence three years 
after extirpation; 47, or 2S.8 per cent, died from recurrence 
within a year; and 32, or 19.6 per cent, lived beyond the year, 
but disappeared from observation before three years — the time 
generally accepted as denoting a cure. Therefore, Tauber ap- 
plies to laryngectomy Stromeyer's classic saying : " Humanity 
will lose nothing if such operations fall into disuse, and sur- 
gery gains no honor by their performance." 

Thyrotomy, or the division of the thyroid for the purpose 
of removing malignant tumors without resection of the cartilage, 
is usually too limited in its results, but sublingual pharyngotomy 
(division of the thyro-hyoid membrane) is useful in operations 
upon the epiglottis. 

Therapeutics. 

Ars. — Burning pains ; dark, offensive, ichorous discharge. 

Phytol. — Dr. A. C. Cowperthwaite {Med. Current, October, 
1891) suggests phytol. as a preventive of carcinoma, and has 
repeatedly removed the " inflamed glandular nodosities " so 
often presaging carcinoma. 

Compare acetic ac, aur., carbo an., conium, hydrast., kali 
sulph., kreos., petrol., and silica, and see - k Malignant Tumors of 
the Nose" and "Malignant Tumors of the Pharynx." 



CHAPTER XXXY. 

Disease of the Perichondrium and Cartilages 
of the Larynx. 

Inflammation of the laryngeal perichondrium is not so 
rare a disease as might appear, judging from the number of 
cases reported. The process may be followed by necrosis and 
loss of a part, or all, of the cartilage, or resolution may occur 
before the death of any portion of it; generally, however, there 
is some permanent thickening about the cartilage, adhesions 
to surrounding tissue, or impaired function. Ankylosis of the 
crico-arytenoid joint is not rare, and usually occurs with the 
vocal band fixed near the median line. This same condition 
may result from rheumatism, gout, typhoid fever, syphilis, 
tonsillitis, and the exanthemata. 

Etiology. — Perichondritis is rarely primary, but, when so, is 
usually due to exposure, especially when overheated. As a 
rule, the disease is the result of some inflammatory or ulcerative 
change passing from the mucous membrane to the deeper 
structures. It follows syphilis, phthisis, cancer, typhoid and 
typhus fevers, small-pox, diphtheria, gout, rheumatism, lupus, 
leprosy, and the deeper-seated acute inflammations of the 
laryngeal mucous membrane, — namely, traumatic and acute 
laryngitis, cedema, erysipelas, phlegmonous laryngitis, accidents, 
operations, the passage of oesophageal bougies in elderly persons 
(von Ziemssen), and continued pressure of the ossified (?) cri- 
coid upon the spinal column while in the dorsal position. 

In the various dyscrasise the poisons sometimes attack the 
cartilage direct and bring about a degeneration of a fibroid 
nature ; or they may affect the perichondrium later and cause 
death of the cartilage. 

Perichondritis occurs mostly in persons of advanced years ; 
children are rarely affected. All of the laryngeal cartilages 
(476) 



DISEASE OF PERICHONDRIUM AND CARTILAGES OF LARYNX. 477 

seem never to be affected at once. The arytenoids and cricoids 
suffer more than the thyroid ; it is doubtful if the epiglottis 
ever undergoes such a change. 

Pathology. — Perichondritis consists of an inflammatory 
thickening of the cartilaginous lining, which soon becomes 
detached from its base, leading to loss of nutrition of the car- 
tilage and usually to its final death and exfoliation. When 
the perichondrium loosens, the cartilage loses its smoothness, 
assumes a roughened surface, and becomes yellow or dirty- 
looking. Calcification favors fibrinous degeneration and death. 

Symptoms. — Symptomatically, there is little on which to 
base an early diagnosis ; even secondary perichondritis may be 
made out with great difficulty, as the primary disease often masks 
the perichondrial changes. In primary or metastatic cases, the 
first symptom calling attention to the larynx is pain in it during 
deglutition or upon pressure over it. There may be hoarseness 
or aphonia ; deep, ineffectual, or suppressed cough, and im- 
paired or suspended respiration dependent upon encroachment. 
Usually there is no fever in the early stages, and, as the disease 
is often very slow in its progress, the affection may last some 
time before the voice or respiration is impaired. 

The laryngoscope gives little indication, at first, of the serious 
nature of the affection, as there may be only slight laryngeal 
congestion ; later, there is more or less swelling of some part of 
the larynx. 

When the arytenoid is involved it is enlarged, but its out- 
lines are not necessarily obliterated, as with oedema or general 
inflammation of the larynx : the mucous membrane may show 
but little change from the normal until the abscess formation 
occasions a boggy or yellow appearance. When ulceration is 
present, the result of some primary laryngeal affection, the diag- 
nosis can only be made by passing a probe to the bottom of the 
ulcer and noting the presence of roughened cartilage. The de- 
tection of this and the exfoliation of portions of cartilage are the 
only sure diagnostic points. If the cartilage be thrown off, a 



478 DISEASES OF THE NOSE AND THROAT. 

corresponding depression will follow and the vocal band be im- 
mobile. The cavity usually granulates and heals very rapidly. 
Should both arytenoids be affected, the lumen of the glottis 
may be so much encroached upon as to result in dyspnoea from 
mechanical hindrance. If the perichondritis end in resolution, 
the crico-arytenoid articulation may become ankylosed, result- 
ing in immobility of the corresponding band and permanent loss 
of voice, unless ankylosis occur with an adducted band ; should 
both bands be so fixed, tracheotomy will be needed. This 
ankylotic condition may be distinguished from paralysis by the 
presence of scars or thickening about the joint. If an abscess 
form, it may burst into the lower part of the pharynx or upper 
part of the oesophagus; and if a fistula form large enough to 
allow the passage of food into the larynx, it will be necessary to 
feed the patient through an oesophageal tube. 

When the thyroid is affected, usually only one lateral plate 
suffers. The laryngoscope reveals swelling of the ventricular 
band and the lateral wall near it. Swelling and hardness may 
be detected externally. 

When the cricoid is attacked, the swelling is usually below 
the vocal bands and, without especial care, may be overlooked. 
The cartilage is rarely affected in its entirety ; the plate (seal) is 
diseased more frequently than the ring, and as a result the ary- 
tenoid cartilages and posterior crico-arytenoid muscles usually 
suffer. Cricoid perichondritis closely simulates chorditis in- 
ferior hypertrophica ; but may usually be differentiated by the 
duration of the affection, the history, or the subsequent progress 
of the affection. The vocal bands generally act sluggishly. 

When the external surface of the thyroid or cricoid is dis- 
eased, the swelling appears externally ; and if an abscess form, 
it will usually burst through the skin, leaving a laryngeal fistula. 
The external swelling, which may be due to abscess or to em- 
physema, is to be differentiated from a bursa, gumma, or 
enlarged gland. 

Prognosis. — The prognosis of disease of the perichondrium 



DISEASE OF PERICHONDRIUM AND CARTILAGES OF LARYNX. 479 

and cartilages is generally grave, though less so in the syphilitic 
form than in the other varieties, except that in syphilis relapses are 
more frequent. Death often results from swelling of the tissues 
and encroachment on the glottic space ; it may follow paralysis 
of the glottic openers ; impaction of pieces of necrosed cartilage 
in the larynx, trachea, or bronchi ; asphyxia due to the bursting 
of an abscess ; or debility incident to either the general disease 
or the long-continued ulcerative and suppurative processes. As 
already stated, a cure may follow with permanent thickening, 
ankylosis, impairment of functional activity, or stenosis. Even 
although one or more cartilages be expelled, the case may re- 
cover, but always with impaired function ; a laryngeal fistula 
may result, either opening into the oesophagus or on to the sur- 
face of the neck. A tracheotomy cannula may be a life-long 
necessity. 

Treatment. — Attention is to be directed to the original 
disease, the early evacuation of the pus, the exfoliation of the 
dead cartilage, and the support of the general system, but, above 
all, to the prevention of the threatening dyspnoea, which may 
require scarification, intubation, or a hasty tracheotomy. The 
general condition should be treated as advised under the various 
headings ; if abscess threaten, the remedies so useful in that 
condition elsewhere are not to be neglected here, and, if pus 
have formed, the use of fer. iod., hepar, kali mur., or silica, may 
suffice ; but early puncture is generally advisable, although, on 
account of the danger of suffocation, it is usually unsafe to open 
a large abscess prior to tracheotomy. The suppurating cavity 
should be occasionally sprayed with iodine, lactic acid, or men- 
thol. Necrosed cartilage can sometimes be extracted with 
laryngeal forceps, thus removing the danger of its lodgment in 
the free air-passage ; but it is at times advisable to open the 
larynx for the purpose of removing or curetting the dead carti- 
lage. If a fistula exist, its edges are to be freshened and united 
with sutures, provided a counter-opening be found within the 
larynx through which the secretions may find an exit, and if 



480 DISEASES OF THE NOSE AND THROAT. 

no necrosed cartilage or other structure be responsible for the 
purulent discharge. In the latter instance the foreign substance 
must be removed. 

Therapeutics. 

Ars. alb. — Especially if there be much debility, burning or 
soreness in the larynx, and serous infiltration. 

Ars. iod. is indicated in cases such as call for the adminis- 
tration of arsenic, but with less cedema. I have found it more 
valuable in practice. 

Calc. carb. — Necrosis of laryngeal cartilages in rachitic, 
emaciated persons. 

Silica. — When there is evidence of a sinus leading to dis- 
eased cartilage, with long-continued discharge which hepar has 
failed to relieve (kali mm*.). 



CHAPTER XXXVI. 

Secondary Laryngeal Diseases. 



LARYNGEAL AFFECTIONS IN TYPHOID AND TYPHUS FEVERS. 

Of the two maladies typhoid is the one more likely to in- 
vade the larynx. In the early stages of the fever, catarrh of 
the larynx is frequent ; in the middle stages, about the second 
week, abrasion of the epithelium and superficial or rhodent 
ulcerations or fissure may occur ; and in the latter stage, or even 
after convalescence seems established, there may appear paraly- 
sis, oedema, perichondritis, chondritis, diphtheria, abscess, fatty 
degeneration of the muscles, or deep ulcers. 

Symptoms. — Since it is so difficult to elicit an expression 
of the symptoms in many cases of typhoid and typhus fevers, 
the laryngeal condition is often overlooked and only made out 
post-mortem. Such examinations reveal ulceration, oedema, 
perichondritis, etc., in 12 to 20 per cent of the cases of typhoid 
and in about 10 per cent of typhus fever. Were it possible to 
detect, post-mortem, the presence of a catarrhal change, the 
number would be much greater. In the majority of cases the 
change seems to be due to the typhoid virus, and is, as a result, 
septic. The following is from Meyhoffer : " In the majority 
of instances the ulcerated follicles in the larynx, as well as the 
ulcerated aggregated glands in the ileum, undergo repair at the 
same time after the typhoid poison has been eliminated from 
the organism." The laryngeal symptoms of typhus fever are 
less severe than those arising from typhoid, and in the former 
there is not the special poison of the latter. 

As suggested, the symptoms are often of little moment 
owing to the diminished cerebral impulse; so that only the 
severe alterations are noted in most instances; even ulceration 
often gives rise to little complaint. As soon as hoarseness is 

(481) 



482 DISEASES OF THE NOSE AND THROAT. 

noted in the course of either of these fevers, a thorough laryngo- 
scopic examination should be made. The early changes are : 
hoarseness or aphonia, difficult or impossible deglutition, and 
difficult respiration, which may lead to threatening or fatal 
dyspnoea. The first paroxysm of dyspnoea may occur when 
the patient sits up in bed ; it may even prove fatal. Cough is 
unusual unless bronchitis be also present ; expectoration is 
usually scanty and sometimes tinged with blood. 

Laryngoscopy inspection may reveal a simple catarrh, an 
erosion of the mucous membrane, ulceration, or abductor paral- 
ysis. The abrasions, superficial ulcers, and fissures are seen on 
various parts of the larynx, but Dr. W. W. Keen, in his "Toner 
Lecture " (No. v, February 17, 1877), says : " The position of the 
ulcers in the larynx is noteworthy. Wherever they may be, 
from the arytenoid to the cricoid, they are almost invariably 
posterior." The oedema is not confined to the epiglottis, 
although it is more frequent there than in the ary-epiglottic 
folds and ventricular bands. Abscesses are found near the car- 
tilages, usually the arytenoid or thyroid ; and particularly about 
the articulations, which, if recovery follow, are usually destroyed 
or ankylosed. Abscesses may burst within the larynx, into 
the pharynx, or externally, resulting in fistula. A perichondri- 
tis may end in abscess formation, or exfoliation of a part or all 
of one or more of the laryngeal cartilages ; the cricoid is most 
frequently affected. Although the larynx may be insensitive, 
pain, especially upon external pressure, is usually a marked 
feature of this affection. The deep ulcers may destroy a part 
or all of the epiglottis, or attack any of the structures of the 
larynx, including muscles and perichondrium ; they may heal 
and leave almost no cicatrix, but, as a rule, decided deformity 
remains, and cicatricial contractions and adhesions sometimes 
exist. Polypoid granulations (rare) may follow the ulceration 
and interfere with respiration and vocalization (see the report 
of a case by the author, Hahnemannian Monthly, February, 
1890). 



LARYNGEAL CHANGES IN MEASLES. 483 

Prognosis. — In the milder forms of the affection, the prog- 
nosis is good; but when oedema, abscess, paralysis, or peri- 
chondritis supervene, the case should be looked upon as serious; 
if promptly treated, however, recovery may follow, and in some 
cases the larynx shows little or no deformity even after consid- 
erable loss of tissue. 

Treatment. — The treatment depends upon the condition 
present : if there exist simple catarrh with hoarseness, nothing 
is necessary beyond the care of the original condition ; when 
convalescence is fairly established, the larynx is usually well, 
For abrasions or fissures, internal measures may be aided by 
local sprayings with one of the petroleum preparations. Paral- 
ysis should be treated with electricity when it does not yield with 
the fever ; but if the posterior cricoarytenoid muscles be para- 
lyzed, tracheotomy is demanded. Perichondritis complicated 
with serious dyspnoea requires tracheotomy. (Edema may need 
scarification, intubation, or tracheotomy. Deep ulceration is 
best treated by the use of internal remedies, if the general 
symptoms will warrant their use, and peroxide of hydrogen,. 
2-per-cent menthol-albolene solution, or fluid cosmolin may be^ 
atomized into the larynx. 

The remedies most suited to the condition will be ars. alb. 7 
ars. iod., fer. phos., hepar, kali iod., kali mur., lach., mere. j. 
rub., mix vom., phos., and sang, can., the special indications for 
which will be found under the headings most suggestive of the 
condition present. 

LARYNGEAL CHANGES IN MEASLES. 

It is not unusual to find a laryngeal catarrh as a prodromic 
symptom of measles ; this, however, usually subsides Avith the 
onset of the eruption ; but a severe form of catarrh may appear 
with superficial ulcerations, more strictly abrasions, of the mu- 
cous membrane. During the course of the disease, spasmodic 
or membranous croup or diphtheria of the pharynx, nose, or 
larynx may appear. 



484 DISEASES OF THE NOSE AND THROAT. 

Symptoms. — The catarrhal change in measles manifests 
itself in a macular or general congestion, which soon undergoes 
slight modification : the laryngeal lining becomes mottled through 
the gradual exfoliation of the epithelium, giving rise to an appear- 
ance closely simulating pseudomembrane, but which must not 
be mistaken for diphtheria. Hoarseness or aphonia, cough, 
and slight expectoration may be noted at an early date ; as the 
eruption appears, profuse expectoration occurs, attended by sub- 
sidence of the hoarseness and cough, if there be no abrasion or 
ulceration, otherwise little or no improvement is then apparent. 

Prognosis. — The prognosis of the catarrhal form is good, 
if treated as soon as the original condition has subsided. If the 
ulceration be considerable or the inflammation marked, it is best 
to advise the patient to speak but little for a time. When 
measles and diphtheria co-exist, the prognosis is better than 
when the latter affection exists alone, as the poison of measles 
:seems to modify both diphtheria and croup. 

Treatment. — Soothing sprays do much to alleviate dryness, 
hoarseness, and pain. When croup or diphtheria occurs, this 
jshould receive entire care. 

LARYNGEAL CHANGES IN SCARLET FEVER. 

The pharynx is generally affected in scarlatina, but the 
larynx usually escapes. The change may be catarrhal or ulcer- 
ative, but it is more usual to find the grave pseudomembranous 
complication characteristic of the pharyngeal disorder. (Edema 
is rare, except in the latter stages of the affection, when it ap- 
pears as the local manifestation of a general anasarca, usually 
ending in the death of the patient. 

The treatment is to be found under the headings of the 
various complications named. 



■&■ 



LARYNGEAL CHANGES IN CHICKEN-POX. 

The laryngeal complications are, as a rule, catarrhal, but 
occasionally there are appearances on the interior of the larynx 



LARYNGEAL CHANGES IN WHOOPING-COUGH. -185 

similar to those found on the cutaneous surface. Little vesicles 
form and burst, leaving a slight abrasion, but no marked ulcer- 
ation and no scar. No special treatment is required. 

LARYNGEAL CHANGES IN SMALL-POX. 

The laryngitis of variola is usually in the form of catarrh, 
which passes away in a short time. It is attended with hoarse- 
ness and cough, and is usually ushered in after the disease has 
been thoroughly established. Almost as frequent as the laryn-i 
geal catarrh is the pustular or " pseudopustular " form of Wag- 
ner, afterward described as vesicular. The elevation of the 
mucous membrane from its underlying bed often gives rise to 
superficial ulcerations, which usually heal kindly with little or 
no treatment. A slight membranous deposit is not infrequent 
in small-pox ; it rarely ends in death, except in certain epi- 
demics. Infiltration of the muscular structure may give rise to 
paralysis. (Edema, either primary or as a complication of acute 
laryngitis, may aggravate the case. The possibility of perichon- 
dritis must be remembered. 

Prognosis. — The prognosis is usually good, as the oedema 
and perichondritis are generally mild, though mechanical meas- 
ures are sometimes demanded. 

Treatment. — Abscess formations may necessitate puncture. 
When the laryngeal complications do not subside as the sys- 
temic condition improves, remedies are to be used in accordance 
with the sequel se present. The drugs of chief value are gels., 
hepar, kali mur., silica, and sulph. 

LARYNGEAL CHANGES IN WHOOPING-COUGH. 

The catarrh of the larynx which always attends whooping- 
cough will not receive attention ; the object of chief importance 
is an ulceration whicli occasionally occurs on the posterior 
laryngeal wall. As a rule, this quickly subsides ; should it con- 
tinue after the cessation of the cough, it is often an indication 
of on-coming phthisis ; the same is true of follicular ulceration 



486 DISEASES OF THE NOSE AND THROAT. 

occurring in the course of pertussis. The presence of false 
membrane is rare. Another and often grave complication of 
whooping-cough is the presence of oedema, which, doubtless, 
often ends the lives of some who are supposed to succumb to the 
paroxysmal asphyxia. The severe paroxysms of coughing, vom- 
iting, etc., occasionally induce laryngeal ecchymoses and haem- 
orrhages. The treatment of ulcers rests chiefly with fer. phos., 
iodine, kali bi., kali mur., and seleniate of soda. Relief from 
oedema is to be sought under the heading " CEdema of the 
Larynx." 

LARYNGEAL CHANGES IN URTICARIA. 

Although rarely recorded, laryngeal complications or alter- 
ations are not uncommon in urticaria. The usual changes con- 
sist of inflammation, papules, and oedema. These occur as 
antecedents or sequelae ; occasionally, the cutaneous and laryn- 
geal affections alternate. 



CHAPTER XXXVII. 

Various Conditions. 



FOREIGN BODIES IN THE LARYNX. 

The most frequent example of this accident is when food 
" goes the wrong- way" ; that is, enters the larynx instead of the 
oesophagus. The resultant spasm is slight, and, as it is usually 
a simple matter to dislodge the intruder by coughing, further 
consideration is unnecessary. Objects less soft and smooth, how- 
ever, cannot be so readily expelled. Thus, a sharp point will 
penetrate the soft tissues and occasion more or less irritation, 
pain, inflammation, and swelling. 

Symptoms. — The symptoms which arise as a result of the 
accidental entrance of foreign bodies into the larynx vary from 
slight, momentary spasm to instant death, depending upon the 
size and position of the body, the irritability of the parts, and 
the previous condition of the patient. The secondary laryngeal 
results may be inflammation, cedema, abscess formation, ulcera- 
tion, perichondritis, or fatal stenosis. The trachea, bronchi, or 
lungs may suffer either secondarily or from the direct passage 
of the foreign body through the glottis to the deeper parts. The 
objects most likely to lodge in the larynx are pins and needles ; 
fish-bones ; splinters ; bristles of tooth-brushes ; pieces of clam- 
and oyster- shells ; beards of rye, oats, and wheat ; small bones ; 
pieces of metal, solder, etc. 

Treatment. — The intruder should be removed at once, 
where possible. For this purpose many devices have been 
practiced ; perhaps the oldest is to strike the patient upon the 
back with the palm of the hand. This may serve to dislodge 
the object, and the cough which follows may expel it ; the same 
result may follow if the bead be thrown quickly forward. Sud- 
denly reversing the bodv sometimes has the desired effect. 

(487) 



488 DISEASES OF THE NOSE AND THROAT. 

These manipulations, however, are more apt to fail than to suc- 
ceed. If the object be within reach, the physician may hook 
it out with his finger ; but, unless great care be exercised, there 
is danger of pushing it farther down. The best plan of pro- 
cedure is always to use the laryngoscope. If the object be 
seen, cocaine should be applied and efforts made to remove it 
with laryngeal or other long, bent forceps. In attempting to 
withdraw a sharp-pointed object, it is very important to note the 
direction from which it entered and to pull it out, if possible, so 
that it shall not cause more than necessary scarification of the 
tissues. 

Sometimes with the greatest care the physician fails to 
remove a small foreign body ; if it occasion little annoyance, 
the patient may be given aeon, and carefully watched, so that 
if severe symptoms arise, such as those which accompany oedema 
or abscess, operation may be resorted to. If the cough be very 
annoying and not improved by aeon., fer. phos. will usually re- 
lieve, although some other remedy may be indicated ; as an 
adjuvant a spray of a 2-per-cent solution of cocaine may be 
used. In a day or two renewed efforts should be made to ex- 
tract the object. In event of a severe inflammation, bell, or 
sang. can. may be given internally and a soothing spray applied 
locally. 

It is sometimes impossible to at once remove burrs, etc., 
from the larynx ; in which case they should be crushed with 
strong forceps ; the symptoms are then to be watched. The 
body either comes away in pieces, or, being loosed by the 
mucous secretions, is coughed out or easily removed with forceps. 
Small objects often remain in the vocal organ for weeks or 
months without producing serious results, finally dislodging 
themselves ; for this reason it is better not to open the larynx 
or trachea, unless urgent symptoms arise, but it is always im- 
portant to make an effort to remove the offender through the 
natural passages. Should the object be sufficiently large to 
immediately cause marked stenosis, threatening life, some of 



FOREIGN BODIES IN" THE LARYNX. 489 

the devices already enumerated may dislodge it ; but if severe 
dyspnoea continue, the trachea should be opened without delay. 
If the foreign body enter the trachea, the latter should be 
opened early. As soon as this is done, the expiratory blast 
may expel the object through the incision ; for this reason it is 
advisable to hold the lips of the wound apart as soon as possible 
after the rings of the trachea have been divided, and not to 
insert the tube for some minutes, if at all. If an extraneous 
object remain in the trachea some time after operation, the 
patient should be left in charge of some one competent to at 
once remove the cannula, should the body become dislodged, 
that it may find its way out through the wound. When the 
natural forces fail to expel it, the extraneous object may some- 
times be detected by the aid of a small mirror heated and passed, 
with reflecting surface downward, through the tracheal opening ; 
if discovered, even though situated in one of the bronchi, an 
attempt should be made to remove it with small forceps, or an 
appropriately bent hook. If in the larynx, efforts should be 
made to remove the object through the natural passages directly 
following the bronchotomy, or as soon as the laryngeal inflam- 
mation has sufficiently subsided. 

Finally, in many of the cases in which a foreign body is 
thought to be in the larynx, none exists at the time the patient 
applies for relief, since by that time the object may have been 
coughed out or swallowed. It usually remains sufficiently long, 
however, to induce decided irritation and leave the impression 
that it is still in the vocal organ. In such cases it is often 
difficult to convince the sufferer that nothing is in the larynx ; 
nor should the physician be too sure of his statement when the 
patient thus persists, as a very small piece of egg-, oyster-, or 
clam- shell, a minute tack, or a hull of oats may be lodged 
within a ventricle of the larynx, or, more probably, in a val- 
lecula or the rugae of the base of the tongue. On this account 
search should not be abandoned until these parts have been 
thoroughly investigated. 



490 DISEASES OF THE NOSE AND THROAT. 



WOUNDS OF THE LARYNX. 

Etiology. — Incised, gunshot, punctured, and lacerated 
wounds may occur at any part of the larynx. The first are the 
most frequent, and are usually the result of suicidal attempts ; 
they are nearly always transverse, and in young subjects are apt 
to be above or through the thyroid cartilage, involving the epi- 
glottis or thyro-hyoid membrane ; while in older persons they 
are lower, owing to the patient's inability to easily raise the chin 
(Mackenzie). If extensive, these wounds may gape widely, in 
which case the danger is often less than when the wound is 
smaller, on account of the difficulty in controlling internal 
haemorrhage in the latter and its greater liability to cause em- 
physema. As a rule, haemorrhage is not severe, and in gaping 
wounds can usually be controlled by throwing the head forward 
and tying it in that position by bandages, etc. 

Gunshot wounds may prove immediately fatal or do very 
little damage to the larynx, as one or two of the shot may pass 
through the thyroid cartilage without wounding any important 
structure ; on the other hand, the greater part or all of the voice- 
box may be carried away. In some rare instances, a pistol- or 
a rifle- ball has fractured the thyroid cartilage without doing 
further damage. 

Punctured wounds are quite rare and are caused by sti- 
lettos, daggers, swords, etc. As a rule, these wounds are small, 
and are apt to produce oedema or emphysema, especially when 
the internal wound does not correspond with that upon the sur- 
face. The oedema may become serious or the emphysema 
extend to the greater part of the body and cause death. 

Lacerated wounds of the larynx are very rare, and are 
produced by the claws of wild beasts, or by large hooks. 

Prognosis and Treatment. — The termination depends upon 
many conditions. Death may follow at once from haemorrhage, 
although, if the patient be seen early, this can usually be con- 
trolled by ligation, torsion, position, or compression ; but if the 



FRACTURES AND DISLOCATIONS OF LARYNGEAL CARTILAGES. 491 

haemorrhage be within the larynx or trachea, and the external 
wound small, it Avill usually be necessary either to enlarge the 
wound and secure the bleeding vessels or open the trachea and 
insert a tampon cannula. Should the internal haemorrhage con- 
tinue long, a clot may form in the larynx or trachea and cause 
death by suffocation. Occasionally a piece of the epiglottis or 
•an arytenoid cartilage .has been severed from the larynx and 
fallen into the air-passages, producing asphyxia. Remotely, 
bands of cicatricial tissue may form during the healing process 
and cause stenosis. Secondary haemorrhage, abscess, or pyaemia 
may complicate the prognosis. Finally, after the case seems to be 
well, granulation tissue may spring up in the region of the old 
wound and cause death by obstruction. 

It must be borne in mind that many patients who would 
otherwise die can be saved by the judicious use of aeon., ars., 
calend., fer. phos., ham., hepar, and silica. It may sometimes 
be necessary to feed the patient through the oesophageal tube ; 
and if the bleeding be liable to recur from a large, gaping 
wound, he should be placed in a sitting attitude with the head 
fastened forward. If the throat be cut in frenzy or during in- 
sanity, the patient had better be bound, hands and feet ; and he 
should be constantly and carefully watched, lest the wound be 
forcibly torn open. 

FRACTURES AND DISLOCATIONS OF THE LARYNGEAL CARTILAGES. 

Etiology. — Direct violence may fracture or displace the 
laryngeal cartilages, or tear the larynx from the trachea. These 
accidents usually occur when the larynx is fixed upon the 
spinal column, as when the larynx is run over by a vehicle, 
stepped upon, hit with a ball, bat, or a belt from a large 
fly-wheel, etc. Hanging, garroting, and the use of the strait- 
jacket may cause similar injuries from compression of the two 
halves of the thyroid cartilage. Fractures are quite rare. 

Symptoms. — Symptomaticallv, there is usually bloody ex- 
pectoration, cough, dyspnoea from oedema or an extensive 



492 DISEASES OF THE NOSE AND THROAT. 

emphysema, temporary or permanent loss of voice, usually 
crepitus, and sometimes displacement and free motion of the 
fragments. The loss of voice is usually sudden and attended 
with a sensation of choking, constriction, and difficult degluti- 
tion. The dyspnoea may come on suddenly and terminate life 
in a few minutes, or be gradual in its development. Necrosis 
with exfoliation of the injured cartilage may complicate the case; 
finally, the larynx may collapse. The thyroid cartilage is the 
one usually fractured, but the cricoid may be implicated either 
separately or at the same time. The arytenoids are rarely frac- 
tured, but may be dislocated. 

Prognosis. — The prognosis is always grave ; the simplest 
fractures, apparently, sometimes prove fatal, the result of oedema 
or emphysema. Few cases recover after fracture of the cricoid, 
but fracture of the thyroid is less grave. These accidents are 
less likely to occur in early youth than after the process of ossifi- 
cation has taken place. 

Treatment. — The patient should be constantly watched, lest 
the presence of oedema or emphysema prove suddenly fatal. 
When the symptoms are very slight, tracheotomy may be de- 
layed, as some cases recover without it ; but the patient who 
has not been tracheotomized or intubated is in danger of suffo- 
cation. The rule is to operate as soon as fracture is found. A 
hard-rubber O'Dwyer tube, if it can be inserted, is more effi- 
cient than a tracheotomy tube, in that collapse of the larynx is 
prevented. Scarification may relieve the oedema or emphysema so 
completely as to obviate both intubation and tracheotomy. Ice 
may be used in the mouth as well as externally. If the trachea' 
be opened, an attempt should be made to replace the fragments 
either by external manipulation or by the use of instruments 
passed through the natural passages or the tracheal wound. 
The larynx has been successfully opened, the cartilages sutured, 
and the loose fragments removed. In the majority of cases, 
following tracheotomy, the larynx is chronically closed ; so that 
the tracheotomy tube must be worn for a long time, or even 



LARYNGOTRACHEAL OZMNA. 493 

permanently. (See treatment of " Stenosis of the Larynx.") 
In order to keep the larynx patulous, Dr. Panas has used a 
rubber bag which he inflates after introducing it into the larynx. 
The remedies most frequently indicated are aeon., ars., fer. 
phos., gels., and sang. 

CONGENITAL DEFORMITIES OF THE LARYNX. 

Congenital deformities of the larynx are very rare. In 
monsters they consist of almost or complete absence of the 
organ ; in other cases, the larynx may be abnormally small or 
remarkably large ; the various cartilages may be deformed, 
bifid, wanting, or decreased in number; but the most frequent 
congenital defects consist of a web passing across the glottis 
between the bands and a bifid epiglottis. 

The majority of deformities are not relievable, and some 
require no treatment. The webbing may be overcome as sug- 
gested under " Stenosis of the Larynx." 

LARYNGO-TRACHEAL OZ.ENA. 

This rare condition, first described by B. Frankel, is closely 
allied to nasal ozaena, with which it is always associated. Here 
the offensive crusts form chiefly on the under surface of the 
vocal bands and in the trachea, thus often interfering with res- 
piration. These subglottic crusts are difficult to expel and may 
become lodged between the vocal bands, interfering with vocali- 
zation. The mucous lining is red and swollen in the affected 
region. The expectoration of these greenish-yellow, offensive 
(ozsenous) plugs rarely occurs except in the morning. When 
present, they give rise to the offensive odor, notwithstanding 
the nose may have been kept scrupulously clean. 

Dr. Lue (Jour, of La/-. <ni<l I'hi//.. January, 1889) recom- 
mends liquid inhalations of thymic acid, 4 to 1000. 



CHAPTER XXXVIII. 
Diseases of the Trachea. 



ACUTE TRACHEITIS. 

Although very usually associated with catarrh of the 
larynx and pharynx, on the one hand, and tracheal inflam- 
mation, on the other, acute tracheitis is occasionally independent 
of these conditions. 

Etiology. — Its causes are those giving rise to the disease 
in the associated organs. 

Symptoms. — The symptoms are those of irritation, fullness, 
burning, pressure, and weight in the tracheal or sternal region. 
Hoarseness is rare, unless the larynx be simultaneously in- 
volved ; but, as a rule, there is marked cough, at first of a dry, 
irritable, tickling character, which later becomes moist and 
attended with a profuse, muco-purulent, purulent, or even bloody 
discharge. This keeps pace with the progress of the inflamma- 
tory change. The early symptoms often simulate croup, in that 
they develop suddenly during the night and are often attended 
by marked spasmodic changes. There may or may not be fever, 
but the pulse is usually accelerated, owing to the cough. Breath- 
ing is never impaired, although inspired air generally gives rise 
to a sensation of dryness and burning and often induces cough. 
This is more marked, however, in the early stages. 

The laryngoscope shows inflammation of the tracheal 
lining, with here and there mucous accumulations. 

The prognosis is good, except that chronic tracheitis some- 
times supervenes. 

Treatment. — The treatment differs but little from that of 

subacute catarrhal laryngitis, especially with reference to the 

remedies employed, but great benefit often follows the local use 

of steam inhalations and oily sprays. Of the latter, none give 

(494) 



TRACHEAL SYPHILIS. 495 

more satisfaction than does eucalyptol or thymol (10 per cent) in 
fluid vaselin. 

CHRONIC TRACHEITIS. 

As stated, this condition may be a sequel of the acute dis- 
order, but is more frequently a result of chronic laryngitis or 
bronchitis. It is most frequent in elderly persons. The patho- 
logical changes are those of chronic laryngitis, the symptoms 
being tickling, fullness, cough, and thick discharge. 

Although difficult to cure, chronic tracheitis is not danger- 
ous. Its treatment is similar to that of chronic laryngitis. Oily 
sprays of eucalyptol, menthol, thymol, and benzoinol are best. 
The chief internal remedies are argent, nit., fer. phos., hepar, 
phos., puis., and verat. vir. 

TRACHEAL SYPHILIS. 

Fortunately, an extensive syphilitic invasion of the trachea 
— independent of the laryngeal complications — is rare. It is 
difficult to diagnose from tracheal phthisis. Its chief manifes- 
tations are gumma, ulceration, necrosis of cartilage, syphilitic 
growths, and cicatricial stenosis. This latter is rarely annular 
but usually longitudinal, and occupies a large portion of the 
tube ; its chief symptom is dyspnoea. Hereditary syphilis may 
attack the trachea, but it is usually the acquired form that 
invades this region. It may show itself in from two months to 
seven years after infection. 

Symptoms. — Cough, tracheal discomfort, and profuse, muco- 
purulent, or bloody expectoration are usually present after the 
disease is fairly located. As occasional symptoms may be noted : 
tracheal or bronchial catarrh ; tracheal dryness, burning, or 
rawness ; dysphagia ; loss of appetite, flesh, and health ; and 
aphonia, either reflex or due to pressure upon the recurrent 
nerve. Dyspnoea is occasioned either by infiltration or cicatricial 
contraction ; it may be inspiratory only, or constant ; and may 
improve gradually, with a decrease of deposit, or suddenly, 
from expulsion of necrosed cartilage. Complications arc: haem- 
orrhage, abscess, pneumonia, etc. 



496 DISEASES OF THE NOSE AND THROAT. 

It may be safely said that ulceration or cicatricial stenosis 
of the trachea, unaccompanied by evident laryngeal or pul- 
monary alteration, is syphilitic ; when so complicated, it is prob- 
ably a combination of syphilis and phthisis. Cancerous growths 
may be excluded by the laryngoscope and by the priority of 
their dyspnoea over the ulceration and cough ; and benign 
growths, by the absence of ulceration at any time, and by the 
laryngoscope. The greatest difficulty may exist in distinguish- 
ing tracheal syphilis in children from enlarged bronchial glands, 

The prognosis depends upon the respiratory calibre. 

Treatment is mechanical and medicinal, and will be found 
under " Syphilis of the Larynx " and " Stenosis of the Larynx." 




Fig. 12;i.— Author's Case of Instruments. 



INDEX. 



Abductors, bilateral paralysis of, 377 
Abscess of larynx, 199, 415, 479 

of nose, 120 

of tonsils, 297 

post-pbaryngeal, 198 
Absent septum, 136 
Accessory cavities, 5 

diseases of, 138 
Acid applicator, 44 
Acinous glands of pharynx, 158 
Action ot vocal bands, 338 
Acute catarrh of larynx, 377, 391 
of pharynx, 163 

follicular pharyngitis, 179 

lacunar tonsillitis, 299 

membranous pharyngitis, 205 

nasal catarrh, 26 

cedema of larynx, 408 

post-nasal catarrh, 314 

purulent rhinitis of children, 59 

rhinitis, 26 

tonsillitis, 292 

tracheitis, 494 

traumatic pharyngitis, 178 

tuberculosis of larynx, 424 
Adam's apple, 323 

forceps, 135 
Adenoid vegetations, 277 
Adenoma of larynx, 461. 

of nose, 120 
Adenotome, Major's, 283 
Adhesions of tonsils to pillars, 302 
Adults, laryngeal spasm of, 379 
Aikins, W. H. B, 423 
Air-compressor, 29 
Alcoholic laryngitis, 390 
Allen, T. F., 38, 116, 174, 191, 318, 385 
Amygdalae, 153 
Amygdalotomy, 306 
Anaesthesia of larynx, 355 

of nose, 91 

of pharynx, 271 
Anatomy of larnyx, 321 

of nose, 3 

of palate, 151 

of pharynx, 155 

of trachea, 339 
Angeioma of larynx, 461 

of nose, 121 
Angeiomatic oedema of larynx, 408 
Agina, cachectic, 170 

ulcerosa, 170 
Ankylosis of crico-arytenoid joint, 476 
Anosmia, 94 



Anterior half-arches, 151 
perforation of, 270 

nares, 3 

occlusion of, 136 

rhinoscopy, 18 
Antrum of Highmore, 6 

diseases of, 138 

empyema of, 139 . 

hydrops of, 140 

Voltolini's method of examination, 140' 
Aphonia, 83 

functional, 366 

spastica, 372 
Aphtha of pharynx, 205 
Apple, Adam's, 323 
Applicator, 44, 173, 400 
Aprosexia, 40 
Arches, anterior half-, 151 

perforation of, 270 
Areas, sensitive, of nose, 93*- 
Armstrong, S. T., 370 
Arteries of larynx, 334 

of nose, 9 

of pharynx, 158 

pulsation of, in posterior wall of phar- 
ynx, 186 
Ary -epiglottic folds, 333 
Arytenoid cartilages, 324 
Arytenoideus muscle, 329 

paralysis of, 363 

ASCHENBRANDT, 11 

Asthma Kopii, 374 

Millari, 374 

thymicum, 374 
Astigmatism, 98 
Atheroma, 98 
Atomizers, 28, 60, 187 
Atrophic nasal catarrh, 47 

pharyngitis, 186 

Bright's disease in, 186 
diabetes in, 186 
Atrophy of larynx, 407 

of septum, 136 

of tonsils, 310 

of vocal bands, 407 
Auto-laryngoscope, 353 

laryngoscopy, 354 

Babchinski, 227 

Bacilli, Klebs-Lceffler, 209 

detection of, 209 
Bjehr, 381 
Baldwin, J. F., 459 
Bands, ventricular, 326 

(497) 



498 



INDEX. 



Bands, vocal, 326 

action of, 338 

atrophy of, 407 
Baeascz, 118 

Bartlett, Clarence, 174 
Bates, 90 
Beebe, C. E, 425 
Beecher, Rev. H. W., 83 
Behring, 224 
Bellocq's cannula, 103 
Bellows, H. P., 121 
Benign growths of larynx, 456 

of nose, 109 
Bergonie, 125 
Bertholle, 203 
Betz, 229 
Beyer, E., 147 
Bifid septum, 136 

uvula, 269 
.Bilateral paralysis of abductors, 377 

of thyro-arytenoids, 360 
Bistou^, laryngeal, 393 
Blackford, C. M., 347 
Blackley, C. H., 84, 87 
Blennorrhosa, chronic, of upper air-passages, 

58 
Bleyer, J. M., 365 

tongue-depressor and incandescent lamp 
of, 140 
Blood-tumors of nose, 120 
Blushing, pharyngeal, 273 
bodies, foreign, in larynx, 487 

in nose, 104 

in pharynx, 260 
Bcericke & Dewey, 55, 233, 454 
Bones, nasal, defects in, 130 

dislocation of, 130 

fracture of, 131 
Boskowitz, 232 
Bosworth, F. H., 98, 128, 130 

clamp of, 134 
Bougies, laryngeal, 446, 448 
Bowman's glands, 10 
Breath, phonetic waste of, 361 
Brigham, G, N., 317 

Bright's disease in atrophic pharyngitis, 186 
Brown, C. W., Haig-, 296, 300 
Brown, M. K, 139, 141 
Browne, L„ 112, 170, 269, 296, 311, 360, 
390, 447 

cutting-dilator of, 447 
Buffum, J. H., 284 
Bursa, pharyngeal, 154 

Cachectic angina, 170 

Cadaveric position of vocal bands, 358 

Calcification of nasal mucous membrane, 108 

Calculi of tonsils, 311 

Cancer of larynx, 420, 429, 442 

of nose, 128 

of tonsils and palate, 258 



Cancerous degeneration, 118 
Cannula, Belloca/s, 103 
Trendelenburg's, 475 
trocar, 200 
Carcinoma of naso-pharynx, 286 

of nose, 128 
Caries and necrosis of nasal bones, 71 
Cartilages of larynx, 321 
diseases of, 476 
dislocation of, 491 
fracture of, 491 
nasal, 3 

defects in, 130 
dislocation of, 130 
Cassaignac, 118 
Casselberry, W. E., 113, 369 
Catarrh, acute, of larynx, 377, 391 
of nose, 26 
of pharynx, 163 
atrophic nasal, 47 
chronic laryngeal, 395 
nasal, 34 
pharyngeal, 170 
hypertrophic nasal, 39 
naso-pharyngeal, acute, 314 

chronic, 315 
subacute, of larynx, 386 
of pharynx, 169 
Catheter, Eustachian, 103 
Caugh try's light angular forceps, 115 
Cautery, galvano-, knives, 45 
Cavernous, erectile tissue, 7 
Cavities, accessory, 5 

diseases of, 138 
Cells, ethmoid, 6 

diseases of, 145 
frontal, 6 

diseases of, 142 
empyema of, 144 
hernia of, 144 
hydrops of, 144 
of Schultze, 8 
sphenoid, 6 
diseases of, 146 
Champlin, H. D, 177 
Charcot, 370 

Charge, A., 54, 76, 116,454 
Cheyne, 376 

Chicken-pox, larynx in, 484 
Chiene, 200 
Child-crowing, 374 
Children, laryngeal spasm of, 374 
Choanse, 3 
Chorditis inferior hypertrophica, 405 

tuberosa, 406, 462 
Chorea of larynx, 372 

of pharynx, 275 
Chronic blennorrhcea of upper air-passages, 58 
catarrh of larynx, 395, 430 

of pharynx, 170 
follicular pharyngitis, 181 



INDEX. 



499 



Chronic hypertrophy of larynx, 405 

laryngeal phthisis, 425 

lateral hypertrophy of pharynx, 172 

nasal catarrh, 34 

oedema of larynx, 413 

post-nasal catarrh, 315 

purulent rhinitis of children, 61 

rhinitis, 34 

tracheitis, 495 
Cleft palate, 136, 269 
Clergyman's sore throat, 181 
Cleveland, C. L., 37 
Cobb, J. P., 381 
Cohen, J. Solis, 270, 296 

tongue-depressor of, 161 
Collier, Mato, 323 
Columnar cartilage, dislocation of, 130 
Concha, 3 

Concretions in tonsils, 311 
Congenital malformations of larynx, 493 
of pharynx, 269 
of septum, 136 

syphilis of larynx, 443 
of pharynx, 250 
Consumption of throat, 423 
Cooper, Robt. T, 90, 142, 174, 284, 309 
Cords, false vocal, 326 ■ 

true vocal, 326 
Coryza, 26 
Cough, nasal, 85 

nervous laryngeal, 382 

COWPERTHWAITE, A. C, 475 

Crico- arytenoid joint, ankylosis of, 476 

muscles, lateral, 329 
paralysis of, 361 
posterior, 328 
paralysis of, 361 
Cricoid cartilage, 324 
Crico-thyroid ligament, 324 

muscles, 328 

paralysis of, 359 
Crico-tracheal ligament, 324 
Croup, 377, 450 

spasmodic, 377, 388, 452 

traumatic, 455 
Croupous pharyngitis, 205 

rhinitis, 65 
Crowing, child-, 374 
Curette finger-tip, 282 

Gottstein's, 282 

Gross', 107 
Curie, 434 

Cushion of epiglottis, 333 
Cutaneous eruption in diphtheria, 211 
Cysts of larynx, 461 

of nose, 112, 121 
CZERMAK, 341 

Dacryocystitis, 105 
Davidson, 420 
Decker, W. M., 30, 451 



Defects of nasal bones and cartilages, 130 

Deformities of larynx, congenital, 493 

de Keghel, 416 

de la Sota, 255 

Delavan, Bryson, 153 

Delstanche, 136 

Demme, 423 

Deviation of septum, 132 

de Villbis' atomizer, 60 

Dewey, W. A., 181 

Diabetes in atrophic pharyngitis, 186 

Dilatation of pharynx, 267 

Dilator of larynx, 446 

Dionisio, Ignazio, 102 

Diphtheria, cutaneous eruptions in, 211 

gangrenous, 214 

myocarditis in, 217 

of larynx, 215 

of nose, 67 

paralysis of heart in, 217 
Diphtheria of pharynx, 207, 294, 457 

diagnosis, 220 

etiology, 207 

pathology, 210 

prognosis, 222 

sequela?, 217 

symptoms, 211 

therapeutics, 230 

treatment, 223 
Diphthonia, 429 
Dislocation of laryngeal cartilages, 491 

of nasal bones and cartilages, 130 
Double nose, 136 
Dry muco-purulent rhinitis, 47 
Dunham, Carroll, 381 
Dunn, W. A., 285 
Dysphonia spastica, 372 

Electrode, laryngeal, 365 
Electrolysis, 114, 118 
Elongation of styloid process, 270 
Elsberg, Louis, 325 
Empyema of antrum, 139 

of frontal sinuses, 144 
Enchondroma of larynx, 461 

of naso-pharynx, 286 

of nose, 122 
Endo-laryngeal operation, 459, 467 
Enlargement of faucial tonsils, 301 

of lingual tonsil, 310 

of Luschka's tonsil, 277 
Epiglottis, 322, 350 

cushion of, 333 

taste function of, 323 
Epilepsy, laryngeal, 370 

nasal, 93 
Epiphora, 108 
Epistaxis, 98 

Epithelioma of larynx, 468 
Eppingek, 162 
Erectile tissue of nose, 7 



500 



INDEX. 



Erosive ulcer, 76 

Eruptions, cutaneous, in diphtheria, 211 

Erysipelas of larynx, 416 

of pharynx, 189 
Ethmoid cells, 6 

diseases of, 145 
Eustachian catheter, 103 

cushions, 24 

tubes, 157 
Eversion of ventricle, 464 
Examination of larynx, 353 

of nasal passages, 14 

of pharynx, 160 

of trachea, 353 
Exner's discovery, 334 
Exostoses of nose, 124 
Expansion, pneumatic, of middle turbinated, 

112 
Exudative pharyngitis, 203 
Eye affections in nasal catarrh, 41 

Facial paralysis, 108 
False croup, 377, 388 

vocal cords, 326 
Farcy, 63 

Faerington, E. A., 32, 33, 104, 235, 384 
Fauces, 151 

pillars of, 151 

tonsils of, 153 
Fauvel, Ch, 342, 473 

lime-light of, 17 
Fehleisen's coccus, 227, 416 
Feeon, 203 

Fibro-cellular tumors of larynx, 459 
Fibroid tumors of naso-pharynx, 284 

of nose, ] 17 
Fibromata of larynx, 459 

of nose, 117 
Fibro-mucous polypi of naso-pharynx, 285 
Finger-guard, 25 
Fissure of septum, 136 
Fistula of larynx, 479 
Flesch, 375 

Folds, ary-epiglottic, 333 
Follicular glands of pharynx, 158 

pharyngitis, acute, 179 
chronic, 181 

tonsillitis, 295 
Foreign bodies in larynx, 487 

in nose, 104 

in pharynx, 260 
Fossa of Rosenmiiller, 155, 157 
Foulis, 354 
Fox, Kingston, 153 
Fracture of cartilages of larynx, 491 

of nasal bands, 131 
Feaenkel, B., 93, 374, 428, 493 

rhinoscopy mirror of, 21 
Feaenkel, C, 224 
Feeedley, Samuel, 235 
Feench, T. R., 329, 354 



Feisch, 58 

Frontal bone, trephining of, 145 
cells, 6 
diseases of, 142 
empyema of, 144 
hernia of, 144 
hydrops of, 144 
Functional aphonia, 366 
Function, resonant, of nose, 12 
respiratory, of nose, 11 
taste, of epiglottis, 323 

Galvano-cautery, 311 
Ganghofnee, 154 
Ganglion, sphenopalatine, 8 
Gangrenous diphtheria, 214 

pharyngitis, 194 
Gaecia, Manuel, 320, 339, 341 
Gargling, Hagen's method of, 165 
Gastrotomy, 472 
Gay, 221 
Geneiul, 101 
Geehaedt, 405 
Glanders, 63 
Glands of larynx, 333 

of pharynx, 153 
Glandular tumors of nose, 120 
Glaucoma, 112 
Glottis, 352 

oedema of, 408 

spasm of, 370, 374 
Goitre, 112 
Goodhaet, 375 
Goodno, W. C, 167, 232 
goodwillie, 134 
Gottstein, 360, 375, 380, 418 

curette of, 282 
Gouty pharyngitis, 238 
Gowees, 334 

Graham's theory of olfaction, 10 
Geauvogl, 142 
Graves' disease, 112 
Geay, L. C, 370 
Geegg, E. R., 378 
Gecening, 312 
Geoneech, 285 
Gross' curette, 107 
Growths, warty, of nose, 120 
Gublee, 195 

Guernsey, H. N., 31, 382 
Gumma of nose, 71 
Gunshot wound of larynx, 490 

Hack, 82 

Hematoma of nose, 99, 120 

of pharynx, 237 
Hasmatophilia, 98 
Haemorrhage of nose, 98 

of pharynx, 237 
Hemorrhagic pharyngitis, 170 
Haemorrhoids, 99 



INDEX. 



501 



Hagen's method of gargling, 165 
Hahn, Eugene, 80, 475 
Hahnemann, Samuel, 116, 404 
Haines, 0. S., 455 
Hale, E. M., 87, 167 
Half^arches, 151 

anterior, perforation of, 270 
Hard palate, 151 
Harris, D. E., 115 
Hart, C. P., 381 
Hay fever, 82 
Head-mirror, 18 
Hearing, defects in, 171 
Heart, paralysis of, in diphtheria, 217 
Helmuth, W. T., 104 
Hendlet, 108 
Henle, 198 
Hereditary syphilis of larynx, 444 

of pharynx, 250 
Hering, C, 191, 193, 318, 384 
Hernia of frontal cells, 144 
Herpes of pharynx, 203 
Heeyng, 171, 200, 431 
Herzog, 203 
Heysinger, I. W., 233 
Highmore, antrum of, 6 

diseases of, 138 

empyema of, 139 

hydrops of, 140 

Voltolini's method of examination of, 
140 
Hill, Wm., 279 
Hilton, 200 
Hinkle, A. W., 239 
Hirsch, 230 
Hodgkin's disease, 462 
Hoopee, 328 
Hospital sore throat, 191 
Houaed, J. G., 234 
Houghton, H. C, 175, 389 
Hutchinson, Peoctee S., 246 
Hydro-encephalocele, 118 
Hydrophobia, 274 
Hydrops antri, 140 

of frontal cells, 144 
Hydrorrhea, nasal, 33 
Hyo-epiglottic ligament, 322 
Hypersesthesia of larynx, 355 

of nose, 91 

of pharynx, 271 
Hyperosmia, 95 

Hypertrophica, chorditis inferior, 405 
Hypertrophic nasal catarrh, 39 
Hypertrophy of larynx, chronic, 405 

of tonsils, 310 
Hysterical aphonia, 366 

Ictus laryngea, 370 
Illumination, 15 
Image, laryngeal, 348 

posterior rhinoscopic, 23 



Incandescent lamp, 140 

Infectious diseases of pharynx, 189 

Inferior hypertrophy of vocal bands, 405 

laryngeal nerve, paralysis of, 357 
Infiltration, serous, of larynx, 413 
Infundibulum, 5 
Ingals, E. Fletchee, 135, 262 
Inhibitor, 283 
Insects in nose, 69 
Insufflator, 52, 316 
Intubation, 228, 394, 417 
Ivatts, E. B., 421, 443, 459 

Jacobi, 219, 300 

Jacobson's organ, duct of, 99 
James, Peossee, 373 
Jaevis, 136 

snare of, 44 
Jeans, Jacob, 166 

Joint, ankylosis of crico-arytenoid, 476 
Jones, E. C, 434 
Jones, Samuel A., 88 
Jousset, Maec, 231 
Jousset, P., 31, 104, 116, 402, 421 
Jurascz's spoons, 134 
Juegens, 462 

Kaposi, 58 

Katsee, 11 

Keen, W. W., 482 

Keghel, de, 416 

Kerato-cricoid muscle, 329 

Key & Retzius, 279 

Killian, Gustav, 153, 348 

King, Wm. R., 51, 116, 297, 389, 407, 443 

Kirk, G. J. W. 228, 232 

KlTASATO, 224 

Klebs-Lceffler bacilli, 209 

detection of, 208 
Klein, E., 207, 209 
Knight, 308 

galvano-cautery tonsillotome of, 308 
Kolisko, 222 
Kolliker, 158 
Kopii, asthma, 374 

Korndcerfer, A., 56, 166, 167, 231, 318 
Kramer's nasal speculum, 14 
Krause, 254, 431 
Krishaber, 370 
Kuhn, 265 

Lacuna? of tonsils, 153 
Lacunar tonsillitis, 299 
Laird, F. F., 89 
Lanne, 226 
Laryngeal chorea, 372 

image, 348 

photography, 354 

vertigo, 370 
Laryngectomy, 171 
Laryngismus stridulus, :'. , 1 



502 



INDEX. 



Laryngo-fissure, 459 
Laryngo-pharynx, 155 
Laryngorrhcea, 397 
Laryngoscope, the, 341 
Laryngoscopy, 345 
auto-, 354 

obstacles to, 346 
Laryngotomy, 467 
Laryngo-tracheal ozaena, 493 
Larvae in nose, 69 
Laryngitis, acute, 377, 391 

alcoholic, 390 

chronic, 395 

subacute, 386 

subglottic, chronic, 405 

submucous, chronic, 405 
Larynx, abscess of, 199, 415 

anatomy of, 321 

atrophy of, 407 

diphtheria of, 207 

erysipelas of, 416 

examination of, 353 

hypertrophy of, 405 

leprosy of, 421 

lupus of, 418, 442 

measles of, 483 

neuroses of, 355 

oedema of, acute, 199, 367, 408 
chronic, 413 

perichondritis of, 476 

phthisis of, 423 

spasm of, 374, 379 

stenosis of, 445 

syphilis of, 438 

tuberculosis of, 423 

tumors of, 456 

typhoid fever of, 481 

typhus fever of, 481 

ventricles of, 332 

wounds of, 490 
Lateral chronic pharyngitis, 172 

crico-arytenoid muscles, 329 
paralysis of, 361 
Leal, Malcolm, 52, 176, 284, 309, 389, 

435, 458 
Leavitt, Sheldon, 381 
Lefferts' insufflator, 316 
Leprosy of larynx, 421 

of pharynx, 255 
Leslie, George, 97 
Levis, R. J„ 307 
Liegeois' theory of olfaction, 10 
Ligament, crico-tracheal, 324 

hyo-epiglottic, 322 

sesamoid, 335 

thyro-hvoid, 323 

vocal, 326 

LlLIENTHAL, S., 383 

Lime-light, 17, 344 
Lingual tonsil, 154 

hypertrophy of, 310 



407, 



Lingual varix, 183 

Link, 139 

Lipoma of larynx, 461 

Lippe, A., 233, 384 

Lippincott, E., 89, 116 

Lcewenberg's forceps, 282 

Lue, 493 

Lupus of larynx, 418 

of nose, 76 

of pharynx, 253 
Luschka's tonsil, 24, 153 

enlargement of, 277 
Lymphadenoma, 462 
Lymphatics of nose, 9 

Mac Donald, Greville, 10 
Macfarland, M., 128 
Mackenzie, Jno. N., 71, 93 
Mackenzie, Morell, 223, 267, 373, 383 r 
433, 490 

laryngeal forceps of, 465 

lime-light of, 17 

snare of, 114 

tonsillotome of, 305 
Majendie, 328 
Major, G. W., 367 

adenotome of, 283 
Malformations of larynx, 493 

of pharynx, 269 

of septum, 136 
Malignant pharyngitis, 194 

rhinitis, 59 

tumors of larynx, 468 
of naso-pharynx, 286 
of nose, 126 
Mandlestamm, 334 
Mann, E. L., 187 
Mannel, 94 
Marsden, J. H., 369 
Martin, 98 
Martin, H. N., 39 
Martin, W. J., 235 
Massage, 187 
Massei, 416, 417, 462 
McBride, P., 258, 370 
McClelland, J. H., 88 
McNeil, A., 232 
Measles of larynx, 483 

of pharynx, 239 
Meati, nasal, 4 
Melanosarcoma of nose, 127 
Membranous laryngitis, 377 

pharyngitis, 205, 295 

rhinitis, 65 
Mendoza, 411 
Meniere's disease, 370 
Meningitis in syphilis, 72 
Merklen, P., 291 
Meyer, 277, 331 

Meyhoffer, Jno., 184, 369, 401. 402, 404,. 
432, 434, 435, 481 



INDEX. 



503 



MlCHELSON, 323 
MlCKULICZ, 141 

Millari, asthma, 374 
Mirror, head-, 18 

laryngeal, 342 

rhinoscopic, 21 
Mitchell, J. S., 403, 435 
Mogiphonia, 374 
Moore, Geo., 30, 403 
Morgagni, ventricles of, 332 
Moese, 53, 75 
Motor changes in larynx, 356 

in pharynx, 274 
Moura, 330 
Moure, 125 
Mouth-breathing, 283 
Muco-purulent dry rhinitis, 47 
Mucous membrane of larynx, 332 
of nose, 7 
of pharynx, 158 

polypi of larynx, 461 
of nose, 109 
Muller, F., 291 
Muscles of larynx, 327 

of pharynx, 159 
Muscular process of arytenoid, 325 
Mycosis of pharynx, 202 
Mtgind, Holger, 118 
Myocarditis in diphtheria, 217 
Myxomata of larynx, 461 

of nose, 109 

Nares, anterior, occlusion of, 136 

posterior, occlusion of, 136 
Nasal cough, 92 

croup, 65 

diphtheria, 67 

epilepsy, 93 

haemorrhage, 98 

hydrorrhoea, 33 

mucous membrane, 7 

passages, examination of, 14 

speech, 14 

stones, 108 

tumors, 109 
Naso-pharyngeal catarrh, acute, 314 

chronic, 315 
Naso-pharynx, 155 

tumors of, 277 
Nebulizers, 166 

Necrosis and caries of nose, 74 
Neidhard, C, 227, 231, 234 
Neoplasms of larynx, 456 
Nerve, inferior laryngeal, paralysis of, 357 

olfactory, 8 

superior laryngeal, paralysis of, 357 
Nerves of larynx, 334 

of nose, 8 

of pharynx, 159 
Nervous aphonia, 366 

laryngeal cough, 382 



Netchateff, 93 
Neuralgia of larynx, 356 

of nose, 92 

of pharynx, 273 
Neuroses of larynx, 355 

of nose, 91 

of pharynx, 271 
Nichol, 60 
Nichol, Jas. E., 266 
Nichol, Thomas, 161, 381 
Nose, anatomy of, 3 

double. 136 

lupus of, 76 

malignant tumors of, 126 

nerves of, 8 

neuroses of, 91 

parasitic affections of, 68 

physiology of, 9 

primary diphtheria of, 67 

scrofula of, 77 

tuberculosis of, 79 
Notta, 95 

Obstacles to laryngoscopy, 346 

to posterior rhinoscopy, 23 
Occlusion of anterior and posterior nares, 136 
O'Dwter, J., 217 

intubation apparatus of, 228 
OSdema of larynx, acute, 64, 377, 408 

chronic, 413 

in hospital sore-throat, 192 

of uvula, 288 
Edematous pharyngitis, 191 
Oesophagus, 159 
Ogle's theory of olfaction, 10 
Olfaction, 9, 94 
Olfactometer, 96 
Olfactory cells of Schultze, 8 

nerve, 8 

tract, 8 
Oliver, 118 
Oro-pharynx, 155 
Osler, Wm, 300 
Osmometer, 96 
Osteoma of nose, 123 
Ozsena of larynx and trachea, 493 

of nose, 47 
Ozsenous odor, causes of, 48 

Pachydermia laryngis, 462 
Palate, anatomy of, 151 

cancer of, 258 

cleft, 136, 269 

hard, 151 

-hook, 23 

physiology of, 151 

soft, 151 

paralysis of, 218 
Palatine arches, 151 

pulsation of, 291 
Paltauf, 222 



504 



INDEX. 



Panas, 493 

Papilloma of larynx, 457 

of nose, 120 
Paresthesia of larynx, 356 

of pharynx, 272 
Paralysis, facial, 108 

of larynx, 356 

of pharynx, 218, 272, 274 
Parasitic affections of nose, 68 

diseases of pharynx, 201 
Parenchymatous pharyngitis, 191 
Parker, W. W., 101 
Parosmia, 96 

Pea-valved tracheotomy tube, 366 
Pemphigus of pharynx, 205 
Perforation of anterior half-arches, 270 

of palate, 78, 136 

of septum, 72, 78, 80, 136 
Perichondritis of larynx, 476, 483 
Periodical vasomotor rhinitis, 82 
Peter, 204 

Peterson, A. C, 176, 432 
Pharyngeal blushing, 273 

paralysis, 272, 274 

recesses, 155 

tonsil, 153 
Pharyngitis, acute follicular, 179 
membranous, 205, 295 
traumatic, 178 

atrophic, 186 

chronic follicular, 181 
lateral, 172 

exudative, 203 

gangrenous, 194 

gouty, 238 

hemorrhagic, 170 

oedematous, 191 

rheumatic, 238 

sicca, 186 
Pharyngocele, 267 
Pharyngoscopy, 160 
Pharynx, acute catarrh of, 163 

anatomy of, 155 

arteries of, 158 

chorea of, 275 

chronic catarrh of, 170 

congenital malformations of, 269 

dilatation of, 267 

diphtheria of, 207 

erysipelas of, 189 

examination of, 160 

foreign bodies in, 263 

glands of, 158 

hasmatoma of, 237 

haemorrhage of, 237 

leprosy of, 255 

lupus of, 253 

measles of, 239 

muscles of, 159 

nerves of, 159 

neuroses of, 271 



Pharynx, paralysis of, 274 

parasitic diseases of, 201 

phthisis of, 240 

physiology of, 151 

scarlet fever of, 240 

scrofula of, 251 

small-pox of, 239 

spasm of, 274 

stenosis of, 264 

subacute catarrh of, 169 

syphilis of, 245 

tumors of, 256 

ulceration of, 200 
Phenomena, reflex pharyngeal, 273 
Philip, A. A., 102 
Phlegmonous pharyngitis, 191, 296 

rhinitis, 62 
Phonatory spasm, 372 
Phonetic waste of breath, 361 
Photography of larynx, 354 
Photophore, 17 
Phthisis of larynx, 420, 423, 441 

of pharynx, 240 
Physiognomy of adenoid vegetations, 27S 
Physiology of larynx, 321 

of nose, 9 

of palate and pharynx, 151 

of trachea, 339 
Pillars of fauces, 151 
Pituitary membrane, 7 
Plethora, 98 

Plica-salpingo-pharyngea, 157 
Pneumatic expansion of middle turbinated 

bone, 112 
Poirier, 333 
Politzer's air-bag, 74 
Pollen catarrh, 82 
Polypi, fibro-mucous, of naso-pharynx, 285 

mucous, of larynx, 459 
of nose, 109 
Pomum Adami, 323 
Posterior crico-arytenoid muscles, 328 
paralysis of, 361 

nares, 3 

rhinoscopic image, 23 

rhinoscopy, 20 
obstacles to, 23 
Post-nasal catarrh, acute, 314 
chronic, 315 

syringe, 37 
Post-pharyngeal abscess, 198 
Primary diphtheria of nose, 67 
Process, muscular, of arytenoid, 325 

styloid, elongation of, 270 

vocal, of arytenoid, 324 
Pseudo-membranous rhinitis, 65 
Ptomaines, 208 
Ptosis, 108 

Pulmonary emphysema, 98 
Pulsation of arteries and veins in posterior 
wall of pharynx, 186 



INDEX. 



505 



Pulsation of uvula and arches, 291 
Punctured wounds of larynx, 490 
Purpura, 98 

Pustules of pharynx, 205 
Putrid pharyngitis, 194 
Pyriform sinuses, 157, 333 
diseases of, 312 

Quinsy, 292 

Racemose glands of pharynx, 158 
Ramsey's theory of olfaction, 10 
Ransford, C, 298 
Raue, C. G., 54, 223 
Recesses, pharyngeal, 155 
Recurrent paralysis, bilateral, 359 

unilateral, 357 
Reflex conditions of nose, 92 

of pharynx, 273 
Rehn, 468 
Relaxed uvula, 289 

Remedies for vocal defects of singers, 383 
Resonant function of nose, 12 
Resorts, hay fever, 83 
Respiration, 11 
Respiratory function of nose, 11 

of pharynx, 155 
Retro-pharyngeal abscess, 198 
Retzius, 279 

Rheumatic pharyngitis, 238 
Rhinitis, acute, 26 

purulent of children, 59 

chronic, 34 

purulent of children, 61 

hypertrophic, 39 

malignant, 59 

muco-purulent, 47 

phlegmonous, 62 
Rhinoliths, 108 
Rhinorrhoea, 33 
Rhinoscleroma, 58 
Rhinoscopic image, posterior, 23 

mirror, 21 
Rhinoscopy, 14 

anterior, 18 

posterior, 20 
Rice, 462 
Ringer, 375 
Rissci, 110 
Roberts, Jno. B., 135 
Rosenmuller's fossee, 155, 157 
Rouge, 118, 146 
Roux, 228 
ruedinger, 159 
Ryland, Peter, 416 

Safety tracheotomy, 415 
Sajous, Chas. E., 15, 135 

snare of, 112 
Sajous' uvula-scissors, 290 
Santorinian cartilages, 325 



Sapejko, 142 

Sappet, 471 

Sarcoma of larynx, 470 

of naso-pharynx, 286 

of nose, 126 
Sarrand, Rene, 426, 434 
Saws, nasal, 122 
Scarification of larynx, 394, 417 
Scarlatina of larynx, 481 

of pharynx, 240, 296 

SCHADLE, 276 

Schech, 186, 215, 230, 253, 373 
Schmidt, Moritz, 433 
Schneiderian mucous membrane, 7 

ScHNITZLER, 407 

Schrotter, 406, 425, 447 

hard-rubber bougies of, 446 
laryngeal tube-forceps of, 466 
metal bougies of, 448 

SCHULDHAM, E. B., 185 

Schultze's olfactory cells, 8 

SCHUESSLER, 129 

Scleroma respiratorium, 58 

rhino-, 58 
Scrofula of nose, 77 

of pharynx, 251 
Scroll bones, 3 
Searle, W. 8., 129, 381 
Secondary laryngeal diseases, 481 
Seibert, A., 226 
Seiler, Carl, 41 
Selfridge, F. M., 178 
Semon, F, 280, 365, 462 
Sensitive areas in nose, 93 
Sensory changes of pharynx, 271 
Septum narium, '3 

absent, 136 

atrophy of, 136 

bifid, 136 

deviation of, 132 

fissure of, 136 

malformations of, 136 

perforation of, 136 

tubercle of, 3 
Serous infiltration of larynx, 413 
Sesamoid ligaments, 325 
Shallcross, I.G., 121, 127 
Sicca, pharyngitis, 486 
Simon, 9 
Singers, remedies for vocal defects of, 

383 
Sinuses, frontal, 6 

diseases of, 142 

pyriform, r>7, 333 
diseases of, 312 
Small-pox of larynx, 485 

of pharynx, 239 
Smedlet, I.'l!., -.".1 
Smock, Ledru P., 311 
Snare, II, 112 
Hnufll.-s, 7.'! 



506 



INDEX. 



Soft palate, 151 

Sota, de la, 255 

Spasmodic croup, 377, 388, 453 

Spasm of larynx, 370, 374, 379 

of pharynx, 274 
Spastica, aphonia and dysphonia, 372 
Speculum, nasal, 14 
Speech, nasal, 14 
Sphenoid cells, 6 

diseases of, 146 
Spheno-palatine ganglion, 8 
Spicee, S., 41 
Spongy bones, 3 
Stammering, 93 

of vocal bands, 372 
Steele's septum-forceps, 135 
Stenosis of larynx, 445 

of nose, 136 

of pharynx, 264 
Stepanow, 58 
Sterling, C. F., 176 

Stoerk,'Carl, 58, 183, 237, 387, 465 
Stones, nasal, 108 
Streptococcus of Fehleisen, 416 
Strickler, D. A., 2S1 
Stricture of larynx, 445 

of pharynx, 264 
Stridulus, laryngismus, 374 
Strometer, 475 
Strubing, 408 
Stuttering, 93 

Styloid process, elongation of, 270 
Subacute laryngitis, 386 

pharyngitis, 169 
Subglottic chronic laryngitis, 405 
Submucous laryngitis, acute, 391 

chronic, 405 
Summer catarrh, 82 
Superior laryngeal nerve, paralysis of, 357 

thyroid notch, 323 
Supernumerary tonsils, 310 
Suppurative pharyngitis, 191 
Symons, Charter, 474 
Syncope, laryngeal, 370 

nasal, 93 
Synechias of nose, 137 
Syphilis of larynx, 419, 438 
congenital, 444 
secondary, 438 
tertiary, 439 

of nose, 71 

of pharynx, 245 
congenital, 250 
secondary, 245 
tertiary, "246 

of trachea, 495 
Syrian sore throat, 207 

Taste function of epiglottis, 323 
Tauber, 475 



TCHERNAIEFF, 221 

Teets' nasal bone-forceps, 124 

Terry, J. A, 37 

Tetanus, 274 

Thomas, Chas. M., 112, 389 

Thomson, W. H., 219 

Throat, 155 

consumption, 423 
Thrombosis, 217 
Thrush of nose, 69 

of pharynx, 201 
Thymicum, asthma, 374 
Thyro-ary-epiglottic muscles, 330 
arytenoid muscles, 331 

paralysis of, 360 
epiglottic muscles, 332 
hyoid ligament, 323 
Thyroid cartilage, 323 

gland-tissue in larynx, 462 
notch, superior, 323 
Thyrotomy, 467 
Tinnitus aurium, 84, 99 
Tongue-depressor, 140, 161 
Tongue, method of depressing, 160 
Tonsil, faucial, 153 

abscess of, 297 
adhesion to half-arches, 302 
anatomy of, 153 
atrophy of, 310 
calculi of, 311 
cancer of, 258 
concretions of, 311 
hypertrophy of, 301 
supernumerary, 310 
lingual, 154 

enlargement of, 310 
Luschka's, 24, 153 
enlargement of, 277 
Tonsillitis, acute, 292 

follicular, 295, 299 
Tonsilloliths, 311 
Tonsillotome, 305 

galvano-cautery, 308 
Tonsillotomy, 306 

haemorrhage following, 306 
Trachea, acute catarrh of, 494 
anatomy of, 339 
chronic catarrh of, 495 
examination of, 353 
physiology of, 339 
syphilis of, 495 
Tracheotomy, 394, 415, 433, 443, 459, 473 

tube, pea-valve, 366 
Transfusion, 103 
Traumatic croup, 455 
Trendelenburg's cannula, 475 
Trephining frontal bone, 145 
Triangular cartilage, 3 
dislocation of, 130 
Trites, W. B., 93 
Trousseau, 203 



INDEX. 



507 



Tubercle of septum, 3 
Tuberculosis of larynx, 423 
acute, 424 
chronic, 425 
diagnosis, 429 
etiology, 423 
pathology, 424 
prognosis, 430 
symptoms, 424 
therapeutics, 434 
treatment, 430 
of nose, 79 
of pharynx, 240 
Tuberosa, chorditis, 406 
Tubes, Eustachian, 157 
Tumors, fibrous, of nose, 117 
glandular, of nose, 120 
malignant, of nose, 126 
of larynx, 456 
of naso-pharynx, 277 
of nose, 109 
of pharynx, 256 
vascular, of nose, 121 
Turbinated bones, 3 
Tueck, 342 

Tyndal's theory of olfaction, 10 
Typhoid fever of larynx, 481 
Typhus fever of larynx, 481 

Ulceration of pharynx, 200 
Ulcerative angina, 170 
Ulcer, erosive, of nose, 76 
Unilateral recurrent paralysis, 357 
Urticaria of larynx, 486 
Uvula, 152 

bifid, 269 

diseases of, 288 

functions of, 152 

oedema of, 288 

pulsation of, 291 

relaxed, 289 

tumors of, 291 
Uvulitis, 288 

Valentine, P. J, 412 
Vallecula?, 158 

diseases of, 312 
Van Baun, W. W., 402 
Van Deusen, E. H., 218 
Van Lennep, W. B, 233 
Varix, lingual, 183 
Vascular tumors of nose, 121 
Vegetations, adenoid, 217 
Veins of larynx, 334 



Veins of nose, 9 

Veins, pulsation of, inposterior wall of phar- 
ynx, 186 
Velum pendulum palati, 151 
Venous sinuses of nose, 7 
Ventricle of Morgagni, 332 

eversion of, 464 
Ventricular bands, 326 
Vertigo, laryngeal, 370 
Vicarious nasal haemorrhage, 98 
Villees, A., 234 
Viechow, 462, 464 

VlSCHEE, C. V., 121 

Vocal bands, 326 

action of, 338 

atrophy of, 407 

cadaveric position of, 358 

paralysis of, 386 

stammering of, 372 
defects of singers, remedies for, 383 
Vocalization, 337 
volkmann, 48 
Voltolini, 5, 20, 140, 354 
von Geauvogl, 142 
von Klein, 125 

nasal bone-forceps of, 126 
von Villees, A., 234 
von Ziemssen, 468 

Wagnee, E., 170, 485 

Waldenburg's pneumatic douche, 134 

Warty growths, 120 

Waste of breath, phonetic, 361 

Watson, Spencee, 118 

Webee, 370 

Wesselhceft, C, 382 

Whistlee, 441, 447 

White's palate retractor, 281 

Whooping-cough, 377, 485 

Winslow, W. H., 169 

Woakes, E., 93, 110, 275 

Woodwaed, 236 

Wounds of larynx, 490 

Weight, Heney, 344 

Wright's snare, 113 

Wrisberg, cartilages of, 325 

Yeesin, 228 

Zaufal, 15 

speculum of, 15 
Ziemssen, 361, 468 
Zuckeekandl, 4, 5, 6, 112, 132 




I 



Revised Edition, 1892. 




(atalogue 



OF THE 



Medical 



Publications 



OF 



THE F. A. DAVIS CO. Publishers, 
Philadelphia, Pa. 

MAIN OFFICE— 1231 Filbert Street, Philadelphia. 
117 W. Forty- Second* Street, New York. 

20 Lakeside Building 1 , 214-220 S. Clark Street, Chicago. 
40 Berners St., Oxford St., London, W., Eng. 



ORDER FROM NEAREST OFFICE. FOR SALE BY ALL BOOKSELLERS. 



SPECIAL NOTICE. 

Prices of books, as given in our catalogues and circulars, include 
full prepayment of postage, freight, or express charges. Customers 

in Canada and Mexico must pay the cost of duty, in addition. :il 
point of destination. 

N. B.— Remittances should be made by Express Money-Order, 
Post-Office Money-Order, Registered Letter, or Draft on New York 
City, Philadelphia, Boston, or Chicago. 

We do not hold ourselves responsible for books sent by mail; to 
insure safe arrival of Looks sent to distant parts, the package should 
be registered. Charges for registering (at purchaser's expense), ten 
cents for every four pounds, or less. 



INDEX TO CATALOGUE. 



BOOKS IN PKKSS AND IN PKEPAKATION, PAGES 31 AND 32. 



TAGE 

Animal of the Universal Medical 

Sciences 27. 28. 29 

Anatomy. 

Practical Anatomy — Roenning 4 

Structure of the Central Nervous Sys- 
tem— Edinger 8 

Charts of the Nervo-Vascular System- 
Price and Eagleton 17 

Synopsis of Human Anatomy — Young . . 25 

Bacteriology. 

Bacteriological Diagnosis— Eisenherg . . 8 

Clinical Charts. 
Improved Clinical Charts — Bashore . ... 3 

Domestic Hygiene, etc. 

The Daughter : Her Health, Education, 
and Wedlock— Capp 5 

Consumption : How to Prevent it, etc.— 
Davis 7 

Plain Talks on Avoided Subjects- 
Guernsey 9 

Heredity, Health, and Personal Beautv — 
Shoemaker . '. . 21 

Electricity. 

Practical Electricity in Medicine and 
Surgery— Liebig and Rone 12 

Electricity* in the Diseases of Women— 
Massey 13 

Fever. 

Fever: its Pathology and Treatment — 

Hare 10 

Hay Fever— Sajous 20 

Gynecology. 

Lessons in Gynecology— Ooodell 9 

Practical Gynecology— Montgomery ... 32 

Heart, Lungs, Kidneys, etc. 

Diseases of the Heart, Lungs, and 

Kidneys— Davis 32 

Diseases of the Heart and Circulation in 
Children— Keating and Edwards ... 12 

Diabetes : its Cause, Symptoms, and 

Treatment — Purdy 17 

Hygiene. 

Climatology of Southern California — 

Remondino 18 

Text-Rook of Hygiene— Rohe' 19 

Materia Medica and Thera- 
peutics. 

Hand-Book of Materia Medica, Pharmacy, 
and Therapeutics— Bowen 4 

Ointments and Oleates — Shoemaker ... 21 

Materia Medica and Therapeutics— Shoe- 
maker 22 

International Pocket Medical Formulary— 
Witherstine 26 



Miscellaneous. 

PAGE 

Rook on the Physician Himself— Cathell . 5 

Oxygen — Deuiarquay and Wallian .... 7 
Record-Book of Medical Examinations for 

Lifc-Insuranct — Keating U 

The Medical Bulletin, Monthly 2 

Physician's Interpreter lfl 

Circumcision — Remondino 18 

Medical Symbolism— Sozinskey 23 

International Pocket Medical Formulary— 

Witherstine . 26 

The Chinese: Medical, Political, and 

Social — ( 'oltman 6 

A B C of the Swedish System of Educa- 
tional Gymnastics— Nissen 15 

Lectures on Auto-Intoxication— Bouchard 32 

Nervous System, Spine, etc. 

Spinal Concussion — Clevenger 6 

Structure of the Central Nervous System 

—Edinger 8 

Epilepsy: its Pathology and Treatment; — 

Hare 10 

Lectures on Nervous Diseases — Ranney . 30 

Obstetrics. 

Childbed: its Management; Diseases and 

Their Treatment— Manton 32 

Eclampsia — Michener and ethers 13 

Obstetric-Synopsis— Stewart 24 

Physiognomy. 

Practical and Scientific Physiognomy— 
Stanton ". 30 

Physiology. 

Physiology of Domestic Animals— Smith . 23 

Surgery and Surgical Operations. 

Practice of Surgery— Packard 32 

Tuberculosis of the Rones and Joints — Senn 32 

Circumcision — Remondino 18 

Principles of Surgery— .Senn 20 

Swedish Movement and Massage. 

Swedish Movement and Massage Treat- 
ment — Nissen 15 

Throat and Nose. 

Journal of Laryngology and Rhinology . 11 

Hay Fever— Sajous 20 

Diphtheria, Croup, etc. — Sanne 25 

Lectures on the Diseases of the Nose and 

Throat. Sajous 31 

"Venereal Diseases. 

Syphilis To-day and in Antiquity— Buret 4 & 32 
Neuroses of the Genito-Urinary System 
in the Male— Ultzmann . . ..*... 24 

Veterinary. 

Age of Domestic Animals — Huidekoper . 11 
Physiology of Domestic Animals — Smith . 23 

Visiting-Lists and Account- 
Books. 

Medical Bulletin Visiting-List or Physi- 

sieians' Call-Record 14 

Physicians' All-Requisite Account-Book . 16 



MEDICAL BULLETIN. A Monthly Journal of Medicine and Surgery. 

Edited by John V. Shoemaker, A.M., M.D. Bright, original, and readable. Articles 
by the best practical writers procurable. Every article as brief as is consistent with the preser- 
vation of its scientific value. Therapeutic Notes by the leaders of the medical profession 
throughout the world. These and many other unique features help to keep The Medical 
Bulletin in its present position as the leading low-price Medical Monthly of the world. 
Subscribe now. 

TERMS: S1.00 a year in advance in United States, Canada, and Mexico. 
Foreign Subscription Terms : England, 5s. ; France, 6 fr. ; Germany, 
6 marks; Japan, 1 yen; Australia, 5s.; Holland, 3 ilorins. 
(2) 



Medical Publications of The F. A. Davis Co. y Philadelphia. 



Bashore's Improved Clinical Chart. 

For the Separate Plotting of Temperature, Pulse, and Respiration. Designed 

for the Convenient, Accurate, and Permanent Daily Recording 

of Gases in Hospital and Private Practice. 

By HARVEY B. BASHORE, M.B, 

C&ei So, InitUd Date 



Name 




Diognoaia .. . ... 


Date. 




1 












160 

160 
140 
130 
120 
110 
100 
90 
60 

ro 

60 
50 
40 

fej 


I 

106" 


MiEMiE 


«em|em|eme 


:mjem|emjemevemev 


EMEMEMIeMCME 


WE 


fcTE 


:MJE 
















104" 
103' 
















___U_ 


- ffl— 


























102' 
101' 
100' 




: ^3-fc3 


























99" 
98" 














: = = 










\ 
















































97" 
55 
50 
45 
40 




























! = £ 


35 
30 
25 

20 


EI \ 


1 


vmm 










I 5 


1---1: 


; : r = -rE: 


"t::-.: : 








:: 


hll .. 


















■ 




** , i 


I 









COPYRIGHTED, 1888, BY F. A. DAVI8. 

50 Charts, in Tablet Form. Size 8 s 12 inches. Price, post-paid, in the United 
States and Canada, 50 Cents, net ; in Great Britain, 3s. 6d. ; in France, 6 fr. 60. 

The above diagram is .a little more than one-flfth (l-SHhe aotnal 

the EinpeT Onrve being tlic 'IVin|iPr:itiiri\ tin; !■■ ■•!■( 1.- Ill- I'iiUi-, :ili'i 111 

r ra of eaehwn easily be kept with but one color ink. , 

II is h.. nrruiiL-.i iliiit .'ill |>n,<-t ,t Mn.-t- "ill tin.l it .in invaluable aid in the troiitin.-nt ol " 

on the i.ac-k of wh chart will be (bnnd ample ipa renlently arranged for recording " I Unii il History ma 

Symptoms" and "Treatment." 

By itensethe physician will seoniv *u"li a .■■>,,,|,i.-i.. r r.l ..f in- rw* -.,<> « ill nmi.io him i > • 

time. Thus he will always have al hand n sonn I Indii idual improvement and benefit In the practice ol hi pi 

the value of which can hardlv l»e overestimated 

(3) 



Medical Publications of The F. A. Davis Co., Philadelphia. 
BOE2YWING 

A Text-Book on Practical Anatomy. 

Including a Section on Surgical Anatomy. 

By Henry C. Boenning, M.D., Lecturer on Anatomy and Surgery in 
the Philadelphia School of Anatomy; Demonstrator of Anatomy in the Medico- 
Chirurgical College, etc., etc. 

Fully illustrated throughout with about 200 "Wood -Engravings. In one 
handsome Octavo volume, printed in extra-large, clear type, making it specially 
desirable for use in the dissecting-room. Nearly 500 pages. Substantially bound 
in Extra Cloth. Also in Oil-Cloth, for use in the dissecting-room without soiling. 

Price, post-paid, in the United States, $2.50, net ; Canada (duty paid), $2.75, net ; 
Great Britain, 14s. ; France, 16 fr. 20. 

This work is fully illustrated throughout ' There is not an unnecessary word in this 

with clear and instructive engravings. It is book of nearly rive hundred pages. As a typo 

not as large as the usual text-books on anatomy, '■, graphical specimen it is elegant. Systematic, 

nor yet so small as many of the ready remem- comprehensive, and intensely practical, 



brances, but it occupies the middle* ground, j heartily commend it to all medical students 
and will find an acceptable place \ " 
Students.— Columbus Med. Journal. 



and will tind an acceptable place with many || and practitioners.— Denver Med. Times. 
Mt 



BO WEN 

Hand-Book of Materia Medica, Pharmacy, 
and Therapeutics. 

By Cuthbert Bowen, M.D., B.A., Editor of "Notes on Practice." 
The second volume in the Physicians' and Students' Ready Reference Series. 
One 12mo volume of 370 pages. Handsomely bound in Dark-Blue Cloth. 

Price, post-paid, in the United States and Canada, $1.40, net ; in Great 
Britain, 8s. 6d. ; in France, 9 fr. 25. 

This excellent manual comprises in its II cated in its title as could well be crowded 
366 pages about as much sound and vain- ! into the compass.— St. Louis Medical and 
able information on the subjects indi- j| Surgieal Journal. 



±> uRET 
SYPHILIS ' n Ancient an d Prehistoric Times. 

With a Chapter on the Rational Treatment of Syphilis in the 
Nineteenth Century. 

By Dr. F. Buret, Paris, France. Translated from the French, with the 
author's permission, with notes, by A. H. Ohmann-Dumesnil, Professor of 
Dermatology and Syphilology in the St. Louis College of Physicians and Surgeons. 

No. 12 in the Physicians' and Students' Ready-Reference Series. 230 pages. 
12mo. Extra Dark-Blue Cloth. 

Price, post-paid, in the United States and Canada, $1.25, net ; in Great 
Britain, 6s. 6d. ; in France, 7 fr. 75. 

This volume, which is one of a series of three (the other two, treating of Syphilis 
in the Middle Ages and in modern times, now in active preparation), gives the most com- 
plete history of Syphilis from prehistoric times up to the Christian Era. 

The subject throughout is treated in a clear, concise manner, and readers 
will find many things which are historically new. 

In order to give some idea of the contents of this first volume, the following 
are cited as among the subjects treated : — 

In What does Syphilis Consist? Origin of the Word Syphilis. The Age of 
Syphilis. Syphilis in Prehistoric Times. Tchoang. — Syphilis Among the Chinese 
5000 Years Ago. Kasa. — Syphilis in Japan in the Ninth Century b.c. Syphilis 
Among the Ancient Egyptians, 1400 b.c. Syphilis Among the Ancient Assyrians 
and Babylonians. Syphilis Among the Hebrews in Biblical Times. Upadansa. — 
Syphilis Among the Hindoos, 1000 b.c. Sukon. — Syphilis Among the Greeks. 
Fkus. — Syphilis at Rome under the Caesars. Conclusion : Rational Treatment of 
Syphilis in the Nineteenth Century. 

(4) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



CAPP 

Her Heal tti, Education, 
Wedlock. 

Homely Suggestions to Mothers and Daughters. 



The Daughter. 



and 



By Willtam M. Capp, M.D., Philadelphia. This is just such a book 
as a family physician would advise his lady patients to obtain and read. 
It answers man}' questions which every busy practitioner of medicine 
has put to him in the sick-room at a time when it is neither expedient 
nor wise to impart the information sought. 

It is complete in one beautifully printed (large, clear tj'pe) 12mo 
volume of 150 pages. Attractively bound in Extra Cloth. 

Price, post-paid, in the United States and Canada, $1.00, net ; In Grea, 



Bnr 



«i : Francs.. S fr. 



(jn 



In the 144 pages allotted to liim he has com- 
pressed an amount of homely wisdom on the 
physical, mental, and moral development of 
the female child from birth to maturity which 
is to be found elsewhere in only the great 
hook of experience. It is, of course, a book 
for mothers, but is one so void of offense in 
expression or ideas that it can safely be recom- 
mended for all whose minds are sufficiently 
developed to appreciate its teachings. — Phila- 
delphia Public Ledger. 

Many delicate subjects are treated with 



skill and in a manner which cannot strike any 
one as improper or bold. The absolute ignor- 
ance in wbicli most young girls are allowed to 
exist, even until adult life, is often productive 
of much misery, both mental and physical. 
Quite a number of books written by physi- 
cians for popular use have been prepared in 
such a way tbat the professional man can read 
between the lines strong bids for popular 
favor, etc. These objectionable features will 
not be found in Dr. Capp's brochure, and for 
this reason it is worthy the confidence of 
physicians.— Medical News. 



CATHBLL 

Book on the Physician Himself 

And Things that Concern his Reputation and Success. 

By D. W. Cathell, M.D., Baltimore, Md. Being the Ninth Edition 
(enlarged and thoroughly revised) of the " Physician Himself, and what 
he should add to his Scientific Acquirements in order to Secure Success." 
In one handsome Octavo Volume of 298 pages, bound in Extra Cloth. 

Thousands of physicians have won success in their chosen profession 
through the aid of this invaluable work. 

This remarkable book has passed through eight (8) editions in less 
than five years. It has just undergone a thorough revison by the author, 
who has added much new matter covering many points and elucidating 
many excellent ideas not included in former editions. 

Price, post-paid, in the United States and Canada, $2.00, net ; in Great 
Britain, lis. 6i; France, 12 ft\ 40. 



I am most favorably impressed with the 
wisdom and tone of the points made in "The 
Physician Himself," and believe the work in 
the hands of a young graduate will greatly en- 
hance his chances for professional success. — 
From Prof. D. Hayes Agneni, Phila., Pa. 

We strongly advise every actual :md intend- 
nig practitioner of medicine or surgery to have 
'• The Physician Himself," and the more it in- 
fluences his future conduct the better he will 
be.— Fro** the Canada Medical and Surgical 
Journal, Montreal. 

In the present edition the entire work baa 
been revised and some new matter Introduced. 
The publisher's part is well done: paper i- 
good and the print large : altogether it is a 
very readable and enjoyable book— Montreal 
Medical Journal 



We have read it carefully and regret much 
that we had not done so earlier and followed 
its precepts. The book is furl of good advice. 
(iet it at once.— Pacific Record of Medicine 
and Surgery. 

We cannot imngine a more profitable invest- 
inent for the junior practitioner than the pur. 

chase and careful Btudy of "The Pnysiciac 

Himself." — Occidental Medical Times. 

To the physician who has discovered thai 
there is something else besides dry book-learn 

ing needed to make hmi a desirable visitor at 

the bedside, we commend this volume, that be 
may assimilate some of the ready crystallized 

worldly wis. |om which otherwise he may he 
many years acquiring by natural processes. — 

North Carolina Medical Journal. 



Medical Publications of The F. A. Davis Co., Philadelphia. 



CLEVBNGBB 

Spinal Concussion. 

Surgically Considered as a Cause of Spinal Injury, and Neuro- 

logically restricted to a certain symptom group, for which 

is Suggested the Designation Erichsen's Disease, 

as One Form of the Traumatic Neuroses. 



By S. V. Clevenger, M.D., Consulting Physician Reese and Alexian 
Hospitals; Lute Pathologist County Insane Asylum, Chicago, etc. 

Special features consist in a description of modern methods of diag- 
nosis by Electricity, a discussion of the controversy concerning hysteria, 
and the author's original pathological view that the lesion is one involv- 
ing the spinal sympathetic nervous system. 

Every Physician and Lawyer should oivn this work. 

In one handsome Royal Octavo Volume of nearly 400 pages, with 
thirty Wood-Engravings. 

Price, post-paid, in United States and Canada, $2.50, net; in Great 
Britain, 14s. ; in France, 15 fr. 



This -work really does, if we may be per- 
mitted to use a trite and hackneyed expres- 
sion, "fill a long-felt want." The subject is 
treated in all its bearings; electro-diagnosis 



receives a large share of attention, and the 
chapter devoted to illustrative cases will be 
found to possess especial importance.— Med- 
ical Weekly Review. 



COLTMA2? 



the CHINESE: 



Their Present and Future; 
Medical, Political, and Social. 



By Robert Coltman ? Jr., M.D., Surgeon in Charge of the Presby- 
terian Hospital and Dispensary at Teng Chow Fu ; Consulting Phy- 
sician of the American Southern Baptist Mission Society, etc. 

Beautifully printed in large, clear type, illustrated with Fifteen Fine 
Engravings on Extra Plate Paper, from photographs of persons, places, 
and objects characteristic of China. 

In one Royal Octavo volume of 212 Pages. "Handsomely bound in 
Extra Cloth, with Chinese Side Stamp in gold. 

Price, post-paid, in United States and Canada, $1.75, net; in Great 
Britain, 10s. ; in France, 12 fr. 20. 



The Chinaman is a source of absolute curi- 
osity to the American, and anything in regard 
to liis relationship to the medical profession 
will prove more than usually attractive to the 
average doctor. Such is the case with the 
work before us. It is difficult to put it aside 
after one has begun to read it. — Memphis Med. 
Monthly. 

Dr. Ooltman has written a very readable 
hook, illustrated with reproduction's of photo- 
graphs taken by himself. — Boston Med. and 
Surg. Journal. 

Attached to a number of hospitals and dis- 
psnsaries, he has had ample opportunity to 
observe the medical aspect of the Chinese. 
The most prevalent diseases are such as affect 
the alimentary tract and eye troubles. Renal 
troubles are also frequent. Skin diseases are 
abundant and syphilis is far from infrequent. 



Erysipelas is rare andenteric fever infrequent. 
Cholera appears in epidemics and is then 
frightfully fatal. Leprosy, of course, is com- 
mon, and the author states that it cannot be 
contagions, as is supposed by many, or it 
would assume a terrible prevalence in China, 
where lepers are permitted to go about free. 

We will not further mention the subjects 
discussed in this excellent book. The style of 
the author is very interesting and taking, and 
much information is given in an entertaining 
manner. The political situation is very intelli- 
gently handled in its various bearings. The 
photo-engravings are handsome and well-ex- 
ecuted, the book in general being gotten up in 
a very artistic manner. We can heartily com- 
mend this work not only to physicians, but t:> 
intelligent lay readers'.— 81. Louis Medical 
Review. 



(6) 



Medical Publications of TJie F. A. Davis Co., Philadelphia. 
DAVIS 

CONSUMPTION: How *° P ^1A ?t" d H ° w t0 

Its Nature, Causes, Prevention, and the Mode op Life, Climate, 
Exercise, Food, and Clothing Necessary for its Cure. 

By N. S. Davis, Jr., A.M., M. D., Professor of Principles and Practice of 
Medicine, Chicago Medical College ; Physician to Mercy Hospital, Chicago ; 
Member of the American Medical Association, etc. 

This plain, practical treatise thoroughly discusses the prevention of Con- 
sumption, Hygiene for Consumptives, gives timely suggestions concerning the 
different climates and the important part they play in the treatmentofthisdisea.se, 
etc., etc., — all presented in such a succinct and intelligible style as to make the 
perusal of the book a pleasant pastime. 

In one neat 12mo volume of 143 pages. Handsomely bound in Extra Cloth, 
with Back and Side Stamps in Gold. 

Price, post-paid, in United States and Canada, 75 Cents, net ; in Great 
Britain, 4s. ; in Prance, 4 fr. 



The questions of heredity, predisposition, 
prevention, and hygienic treatment of con- 
sumption are simply and sensibly dealt with. 
The chapters on how to live with tuberculosis 
are excellent.— Indiana Medical Journal. 

The author is very thorough in his dis- 
cussion of the subject, and the practical hints 
which he gives are of real worth and value. 



His directions are given in such a manner as 
to make life enjoyable to a consumptive 
patient and not a burden, as is too frequently 
the case. — Weekly Medical Review. 

There is much good ordinary common 
sense in this book of only 150 pages. The port 
of the brochure devoted to Climatology is espe- 
cially commendable. — Denver Medical Times. 



DEMABQUAY 

f\ f% A Practical Investigation of the Clinical 

UN UXVOCn. and Therapeutic Value of the Gases 
J ** in Medical and Surgical Practice, 

With Especial Reference to the Value and Availability of Oxygen 
Nitrogen, Hydrogen, and Nitrogen Monoxide. 

By J. N. Demarquay, Surgeon to the Municipal Hospital, Paris, and of the 
Council of State ; Member of the Imperial Society of Surgery, etc. Translated, 
with notes, additions, and omissions, by Samuel *S. Wallian, A.M., M. D.; Ex- 
President of the Medical Association of Northern New York ; Member of the New 
York County Medical Society, etc. 

In one handsome Octavo Volume of 316 pages, printed on fine paper, in the 
best style of the printer's art, and illustrated with 21 Wood-Cuts. 

Price, post-paid, in United States and Canada, Cloth, $2.00, net; Half- 
Russia, $3.00, net. In Great Britain, Cloth, lis. Sd. ; Half-Russia, 
17s. Sd. In Prance, Cloth, 12 fr. 40; Half-Russia, 18 fr. GO. 
For some years past there has been a growing demand for something more 
satisfactory and more practical in the way of literature on the subject of aero- 
therapeutics. On all sides professional men of standing and ability are turning 
their attention to the use of the gaseous elements, as remedies in disease, as well 

as sustaineis in health. In prosecuting their inquiries, the first hindrance lias 
been the want of any reliable or satisfactory literature on the subject. 

This work, translated from the French of Professor Demarquay, contains 
also a very full account of recent English, German, and American experiences, 
prepared by Dr. Samuel 8. Wallian, of New York, whose experience in this field 
has been more extensive than that of any other American writer <>n the subject. 



This is a handsome volume of 800 pages, 
large print, on good paper, and nicelv llTus- 
ated. Although nominally pleading for the 
ie of oxygen inhalations, the author shows in 
philosophical manner bow ranch greater 
md physicians might do if they more fully 
•predated the value of fresh-air exercise and 



The lior.ii should be widely read, for to 
marty it will bring the addition of a new 
weapon to their therapeutic armament.— 
Northwestern Lancet. 



Altogether the i><><>k is m valuable one, 
which wilt lie found of Bervice to the imsv 
scs of the lungs, kid- practitioner who wishes to keep abreast of 
•, ami skin.' We commend in perusal t" Hi.' Improvements in therapeutics.— Medical 
readers. — The Canada Medical Record. -Y< us. 

(7) 



Medical Publications of The F. A. Davis Co., Philadelphia. 
EISEJSBERG 

Bacteriological Diagnosis. 

Tabular Aids for Use in Practical Work. 

By James Eisenberg, Ph.D., M.D., Vienna. Translated and augmented, 
with the permission of the author, from the second German Edition, hy Norval 
H. Pierce, M.D., Surgeon to the Out-Door Department of Michael Reese 
Hospital ; Assistant to Surgical Clinic, College of Physicians and Surgeons, 
Chicago, 111. 

Nearly 200 pages. In one Royal Octavo volume, handsomely hound in 
Cloth and in Oil-Cloth (for laboratory use). 

Price, post-paid, in the United States and Canada, $1.50, net; in Great 
Britain, 8s. 6d. ; in Prance, 9 fr. 35. 

This hook is a novelty in Bacteriological Science. It is a work of great 
importance to the teacher as well as to the student. It will be of inestimable 
value to the private worker, and is designed throughout as a practical guide in 
laboratory work. It is arranged in a tabular form, in which are given the specific 
characteristics of the various well established bacteria, so that the worker may, at 
a glance, inform himself as to the identity of a given organism. 

There is also an appendix, in which is given, in a concise and practical form, 
the technique employed by the best laboratories in the cultivation and staining 
of bacteria; the composition and preparation of the various solid, semi-solid, and 
fluid media, together with their employment ; a complete list of stains and re- 
agents, with formulae for same ; the methods of microscopic examination of 
bacteria, etc., etc., etc. 



EDINGER 

Twelve Lectures on the Structure of the 
Central Nervous System. 

For Physicians and Students. 

By Dr. Ludwig Edinger, Frankfort-on-the-Main. Second Revised Edi- 
tion. With 133 Illustrations. Translated by Willis Hall Vittum, M.D., St. 
Paul, Minn. Edited by C. Eugene Riggs, A.M , M.D., Professor of Mental and 
Nervous Diseases, University of Minnesota ; Member of the American Neuro- 
logical Association. 

The illustrations are exactly the same as those used in the latest German 
edition (with the German names translated into English), and are very satisfac- 
tory to the Physician and Student using the book. 

The work is complete in one Royal Octavo Volume of about 250 pages, 
bound in Extra Cloth. 

Price, post-paid, in the United States and Canada, $1.75, net ; in Great 
Britain, 10s. : in Prance, 12 fr. 20. 



One of the most instructive and valuable 
works on the minute anatomy of the human 
brain extant. It is written "in the form of 
lectures, profusely illustrated, and in clear 
language.— The Pacific Record of Medicine 
and Surgery. 

Since the first works on anatomy, up to the 
present day. no work has appeared on the sub- 
ject of the general and minute anatomy of the 
central nervous system so complete and ex- 
haustive as this work of Dr. Ludwig Edinger. 
Being himself an original worker, and having 
the benefits of such masters as Stilling, Wei- 
geit, Geilach, Meynert, and others, he has 



(8) 



succeeded in transforming the mazy wilder- 
ness of nerve fibres and cells into a district of 
well-marked pathways and centres, and by so 
doing lias made a pleasure out of an anatom- 
ical bugbear.— The Southern Medical Record. 

Every point is clearly dwelt upon in the text, 
and where description alone might leave a 
subject obscure clever drawings and diagrams 
are introduced to render misconception of the 
author's meaning impossible. The book is 
eminently practical. It unravels the intricate 
entanglement of different tracts and paths in 
a way that no oiher book has done so explic- 
itly or so concisely. — Northwestei-n Lancet. 



Medical Publications of The F. A. Davis Go., Philadelphia. 



GOOJDELL 

Lessons in Gynecology. 

By William Goodell, A.M., M.D., etc., Professor of Clinical Gyne- 
cology in the University of Pennsylvania. 

This exceed in gly valuable work, from one of the most eminent 
specialists and teachers in gynecology in the United States, is now 
offered to the profession in a much more complete condition than either 
of the previous editions. It embraces all the more important diseases 
and the principal operations in the field of gynecology, and brings to 
bear upon them all the extensive practical experience and wide reading 
of the author. It is an indispensable guide to every practitioner who 
has to do with the diseases peculiar to women. Third Edition. With 
112 illustrations. Thoroughly revised and greatly enlarged. One volume, 
large octavo, 578 pages. 

Price, in United States and Canada, Cloth, $5.00; Pull Sheep, $6.00. Discount, 

20 per cent., making it, net, Cloth, $4.00; Sheep, $4.80. Postage, 27 

cents eztra. Great Britain, Cloth, 22s. 6d. ; Sheep, 28s., 

post-paid. Prance, 30 fr. 80. 



It is too good a book to have been allowed to 
remain out of print, and it has unquestionably 
been missed. The author has revised the work 
with special care, adding to each lesson such 
fresh matter as the progress in the art ren- 
dered necessary, and he has enlarged it by the 
insertion of six new lessons. This edition' will, 
without question, be a* eagerly sought for as 
were its predecessors.— American Journal of 
Obstetrics. 

His literary style is peculiarly charming. 
There is a directness and simplicity about it 
which is easier to admire than to copy. His 
chain of plain words and almost blunt expres- 
sions, his familiar comparison and homely 
illustrations, make his writings, like his lec- 



tures, unusually entertaining. The substance 
of his teachings we regard as equally excel- 
lent.— Philadelphia Medical and Surgical 
Reporter. 

Extended mention of the contents of the 
book is unnecessary; suffice it to say that 
every important disease found in the female 
sex is taken up and discussed in a common- 
sense kind of a way. We wish every physician 
in America conld read and carry out the sug- 
gestions of the chapter on "the sexual rela- 
tions as causes of uterine disorders — conjugal 
onanism and kindred sins. 1 ' The department 
treating of nervous counterfeits of uterine 
diseases is a most valuable one.— Kansas City- 
Medical Index. 



GUJEBJVSEY 

Plain Talks on Avoided Subjects. 

By Henry N. Guernsey, M.D., formerly Professor of Materia Medica 
and Institutes in the Hahnemann Medical College of Philadelphia; 
author of Guernsey's " Obstetrics," including the Disorders Peculiar to 
Women and Young Children ; Lectures on Materia Medica, etc. The 
following Table of Contents shows the scope of the book : 

Contents. — Chapter I. Introductory. II. The Infant. III. Child- 
hood. IV. Adolescence of the Male. V. Adolescence of the Female. 
VI. Marriage: The Husband. VII. The Wife VIII. Husband and 
Wife. IX. To the Unfortunate. X. Origin of the Sux. In one neat 
16mo volume, bound in Extra Cloth. 

Price, post-paid, in the United States and Canada, $1.00 ; Great Britain, 
6s. ; France, 6 fr. 20. 



Medical Publication?, of Tlie F. A. Davis Co., Philadelphia. 



HARE 

Epilepsy: Its Pathology and Treatment. 

Being an Essay to which was Awarded a Prize of Four Thousand 

Francs by the Academie Royale de Medecine de Belgique, 

December 31, 1889. 

By Hobart Amory Hare, M.D. (Univ. of Penna.), B.Sc, Professor of 
Materia Medica and Therapeutics in the Jefferson Medical College, Phila.; 
Physician to St. Agnes' Hospital and to the Children's Dispensary of the Chil- 
dren's Hospital ; Laureate of the Royal Academy of Medicine in Belgium, of 
the Medical Society of London, etc. ; Member of the Association of American 
Physicians. 

No. 7 in the Physicians' and Students' Beady-Reference Series. 12mo. 228 
pages. Neatly bound in Dark-blue Cloth. 

Price, post-paid, in United States and Canada, $1.25, net; in Great 
Britain, Ss. 6d. ; in France, 7 fr. 75. 



It is representative of the most advanced 
views of the profession, and the subject is 
pruned of the vast amount of superstition and 
nonsense that generally obtains in connection 
with epilepsy. — Medical Age. 

Every physician who would get at the gist 
of all that is worth knowing on epilepsy, and 
who would avoid useless research among the 
mass of literarv nonsense which pervades all 
medical libraries, should get this work.'*— The 
Sanitarian. 

It contains all that is known of the pathology 
of this strange disorder, a clear discussion of 
the diagnosis from allied neuroses, and the 
very latest therapeutic measures for relief. 



It is remarkable for its clearness, brevity, and 
beauty of style. It is, so far as the reviewer 
knows, altogether the best essay ever written 
upon this important subject. — Kansas City 
Medical Index. 

The task of preparing the work must have 
been most laborious, but we think that Dr. 
Hare will be repaid for his efforts by a wide 
appreciation of the work by the profession ; 
for the book will be instructive to those who 
have not kept abreast with the recent litera- 
ture upon this subject. Indeed, the work is a 
sort of Dictionary of epilepsy— a reference 
guide-book upon the subject. — Alienist and 
Neurologist. 



HARE 

Fever: Its Pathology and Treatment. 

Being the Boylston Prize Essay of Harvard University for 1890. 
Containing Directions and the Latest Information Con- 
cerning the Use of the So-Called Anti- 
pyretics in Fever and Pain. 

By Hobart Amort Hare, M.D. (Univ. of Penna.), B.Sc, Professor of 
Materia Medica and Therapeutics in the Jefferson Medical College, Phila. ; 
Physician to St. Agnes' Hospital and to the Children's Dispensary of the Chil- 
dren's Hospital; Laureate of the Royal Academy of Medicine in Belgium, of the 
Medical Society of London, etc.; Member of the Association of American 
Physicians. 

No. 10 in the Physicians' and Students' Ready -Reference Series. 12mo. 
Neatly bound in Dark-blue Cloth. 

Illustrated with more than 25 new plates of tracings of various fever cases, 
showing beautifully and accurately the action of the Antipyretics. The work 
also contains 35 carefully prepared statistical tables of 249 cases showing the 
untoward effects of the antipyretics. 

Price, post-paid, in the United States and Canada, $1.25, net; in Great Britain, 
6s. 6d. ; in Prance, 7 fr. 75. 



As is usual with this author, the subject is 
thoroughly handled, and much experimental 
and clinical evidence, both from the author's 
experience and that of others, is adduced in 
support of the view taken.— New York Medical 
Abstract. 

The author has done an able piece of work 
in showing the facts as far as they are known 
concerning the action of antipyrin, anti- 
febrin, phenacetin, thallin, and salicylic acid. 
The reader will certainly find the work one of 



the most interesting of its excellent group, 
the P7iysicians' and Students' Ready-Refer- 
ence Series. — 77te Dosimetric Medical Review. 

Such books as the present one are of service 
to the student, the scientific therapeutist, and 
the general practitioner alike, for much can 
be found of real value in Dr. Hare's book, with 
the additional advantage that it is up to the 
latest researches upon the subject.— Univer- 
sity Medical Magazine. 



(10) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



Age of the Domestic Animals. 

Being a Complete Treatise on the Dentition of the Horse, Ox, 

Sheep, Hog, and Dog, and on the Various Other Means of 

Determining the Age of these Animals. 

By Rush Shippen Huidekoper, M.D., Veterinarian (Alfort, France) ; Professor of 
Sanitary Medicine and Veterinary Jurisprudence, American Veterinary College, New York ; 
Late Dean of the Veterinary Department, University of Pennsylvania. 

Complete in one handsome Royal Octavo volume of 225 pages, bound in Extra Cloth. 
Illustrated with 200 engravings. 

Price, post-paid, in the United States and Canada, $1.75, net ; in Great 
Britain, 10s. ; in France, 12 fr. 20. 

This work presents a careful study of all that has been written on the subject from 
the earliest Italian writers. The author has drawn much valuable material from the ablest 
English, French, and German writers, and has given his own deductions and opinions, 
whether they agree or disagree with such investigators as Bracy Clark, Simonds (in Eng- 
lish), Girard, Chauveau, Leyh, Le Coque, Goubaux, and Barrier (in German and French). 



The literary execution of the book is very 
satisfactory, the text is profusely illustrated, 
and the student will rind abundant means in 
the cuts for familiarizing himself with the 
various aspects presented by the incisive 
arches during the different stages of life. 
Illustrations do not always illustrate ; these 
do.— Amer. Vet. Review. 

Although written primarily for the veteri- 



narian, this book will be of interest to the 
dentist, physiologist, anatomist, and physician. 
Its wealth of illustration and careful prepara- 
tion are alike commendable. — Chicago Med. 
Recorder. 

It is profusely illustrated with 200 engrav- 
ings, and the text forms a study well worth the 
price of the book to every dental practitioner. 
—Ohio Journal of Dental Sciences. 



Journal of Laryngology, Rhinology, 
and Otology. 

An Analytical Record of Current Literature Relating to the 
Throat, Nose, and Ear. Issued on the First of Each Month. 

Edited by Dr. Norris Wolfexden, of London, and Dr. John Macinttre, of Glas- 
gow, with the active aid and co-operation of Drs. Dundas Grant, Barclay J. Baron, and 
Hunter Mackenzie. Besides those specialists in Europe and America who have so ably 
assisted in the collaboration of the Journal, a number of new correspondents have under- 
taken to assist the editors in keeping the Journal up to date, and furnishing it with matters 
of interest. Amongst these are: Drs. Sajous, of Philadelphia; Middlemass Hunt, of 
Liverpool ; Mellow, of Rio Janeiro ; Sedziak, of Warsaw ; Draispul, of St. Petersburg, etc. 
Drs. Michael, Joal, Holger Mygind, Prof. Massei, and Dr. Valerius Idelsou will still collab- 
orate the literature of their respective countries. 

Price, 13s. or $3.00 per annum (inclusive of Postage). For single copies, however, 
a charge of Is. 3d. (30 Cents) will be made. Sample Copy, 25 Cents. 



KEATING 

Record-Book of Medical Examinations 

For Life-Insurance. 

Designed by Jonx M. Keating, M.D. 

This record-book is small, neat, ami complete, and embraces all the principal points 
that are required by the differenl companies. It is made in two sizes, viz. ; No. 1 , covering 
one hundred (100) examinations, and No. 2, covering two hundred (200) examinations. 
The size of the book is 7 x '•$% inches, and can be conveniently carried In the pocket. 

CT. S. and Canada. Great Britain. Prance. 



No. 1. For 100 Examinations, in Cloth, - - $ .50, Net 
No. 2. For 200 Examinations, in Full 

Leather, with Side Flap, - - - - 1.00, " 



3s. 6d. 



3s, 



3 fr. 60 



6 fr. 30 



Medical Publications of The F. A. Davis Co., Philadelphia. 
KEATING and EDWARDS 

Diseases of the Heart and Circulation. 

In Infancy and Adolescence. With an Appendix entitled " Clinical 
Studies on the Pulse in Childhood." 

By John M. Keating, M.D., Obstetrician to the Philadelphia Hospital, 
and Lecturer on Diseases of Women and Children; Surgeon to the Maternity 
Hospital; Physician to St. Joseph's Hospital; Fellow of the College of Physicians 
of Philadelphia, etc.; and William A. Edwards, M.D., Instructor in Clinical 
Medicine and Physician to the Medical Dispensary in the University of 
Pennsylvania; Physician to St. Joseph's Hospital; Fellow of the College of 
Physicians; formerly Assistant Pathologist to the Philadelphia Hospital, etc. 

Illustrated by Photographs and Wood-Engravings. About 225 pages. Oc- 
tavo. Bound in Cloth. 

Price, post-paid, in the United States and Canada, $1.50, net; in Great 
Britain, 8s. 6d. ; in France, 9 fr. 35. 



Drs. Keating and Edwards have produced a 
work that will give material aid to every 
doctor in his practice among children. The 
style of the book is graphic and pleasing, the 
diagnostic points are explicit and exact, and 
the therapeutical resources include the novel- 
ties of medicine as w.ell as the old and tried 
agents. — Pittsburgh Med. Review. 



It is not a mere compilation, but a systematic 
treatise, and bears evidence of considerable 
labor and observation on the part of the 
authors. Two fine photographs of dissections 
exhibit mitral stenosis and mitral regurgita- 
tion ; there are also a number of wood-cuts. 
—Cleveland Medical Gazette. 



LIEBIG and ROUE 

Practical Electricity in Medicine ^ Surgery. 

By G. A. Liebig, Jr., Ph D., Assistant in Electricity, Johns Hopkins 
University ; Lecturer on Medical Electricity, College of Physicians and Surgeons, 
Baltimore ; Member of the American Institute of Electrical Engineers, etc. ; and 
Oeorge H. Rohe, M.D., Professor of Obstetrics and Hygiene, College of Physi- 
cians and Surgeons. Baltimore ; Visiting Physician to Bay View and City Hos- 
pitals ; Director of the Maryland Maternite ; Associate Editor "Annual of the 
Universal Medical Sciences," etc. 

Profusely Illustrated by Wood-Engravings and Original Diagrams, and 
published in one handsome Royal Octavo volume of 383 pages, bound in Extra 
Cloth. 

The constantly increasing demand for this work attests its thorough relia- 
bility and its popularity with the profession, and points to the tact that it is 
already the standard work on this very important subject. The part on Physical 
Electricity, written by Dr. Liebig, one of the recognized authorities on the 
science in the United States, treats fully such topics of interest as Storage Bat- 
teries, Dynamos, the Electric Light, and the Principles and Practice of Electrical 
Measurement in their Relations to Medical Practice. Professor Robe, who writes 
on Electro-Therapeutics, discusses at length the recent developments of Electricity 
in the treatment of stricture, enlarged prostate, uterine fibroids, pelvic cellulitis, 
and other diseases of the male and female genito-urinary organs. The applica- 
tions of Electricity in dermatology, as well as in the diseases of the nervous 
system, are also fully considered. 

Price, post-paid, in the United States and Canada, $2.00, net; in Great 
Britain, lis. 6d. ; France, 12 fr. 40. 



Any physician, especially if he be a beginner 
in electro-therapeutics, will be well repaid by 
a careful study of this work by Liebig and 
Robe. For a work on a special subject the 
price is low, and no one can give a good ex- 
cuse for remaining in ignorance of so impor- 
tant a subject as electricity in medicine.— 
Toledo Medical and Surgical Reporter. 

The entire work is thoroughly scientific and 
practical, and is really what the authors have 
aimed to produce, "a trustworthy guide to 
the application of electricity in the practice of 
medieine and Surgery." — New York Medical 
Times. 



In its perusal, with each succeeding page, 
we have been more and more impressed with 
the fact that here, at last, we have a treatise 
on electricity in medicine and surgery which 
amply fulfills its purpose, and which is sure of 
general adoption by reason of its thorough 
excellence and superiority to other works in- 
tended to cover the same' field.— Pharmaceu- 
tical Era. 

After carefully looking over this work, we 
incline to the belief tltat the intelligent physi- 
cian who is familiar with the general subject 
will be greatly interested and profited.— 
American Lancet. 



(12) 



Medical Publications of The F. A. Davis Co., Philadelphia. 
MASSE Y 

Electricity in the Diseases of Women. 

With Special Reference to the Application of Strong Currents. 



By Gr. Betton Massey, M.D., Physician to the Gynaecological Department 
of the Howard Hospital ; late Electro-therapeutist to the Philadelphia Orthopaedic 
Hospital and Infirmary for Nervous Diseases, etc. Second Edition. Revised 
and Enlarged. With New and Original Wood-Engravings. Handsomely hound 
in Dark-Blue Cloth. 240 pages. 12mo. No. 5 in the Physicians' and Students' 
Ready -Reference Series. 

This work is presented to the profession as the most complete treatise yet 
issued on the electrical treatment of the diseases of women, and is destined to 
fill the increasing demand for clear and practical instruction in the handling and 
use of strong currents after the recent methods first advocated hy Apostoli. The 
whole suhject is treated from the present stand-point of electric science with new 
and original illustrations, the thorough-studies of the author and his wide clinical 
experience rendering him an authority upon electricity itself and its therapeutic 
applications. The author has enhanced the practical value of the work hy 
including the exact details of treatment and results in a number of cases taken 
from his private and hospital practice. 

Price, post-paid, in the United States and Canada, $1.50, net; in Great 
Britain, 8s. 6d. : in France, 9 fr. 35. 



A new edition of this practical manual at- 
tests the utility of its existence and the recog- 
nition of its merits. The directions are simple, 
easy to follow and to put into practice ; the 
ground is well covered, and nothing is assumed, 
the entire book being the record of expe- 
rience. — Journal of Nervous and Mental 
Diseases. 

It is only a few months since we noticed the 
first edition of this little book ; and it is only 
necessary to add now that we consider it the 



best treatise on this subject we have seen, and 
that the improvements introduced into this 
edition make it more valuable still. — Boston 
Medical and Surgical Journ. 

The style is clear, but condensed. Useless 
details are omitted, the reports of cases being 
pruned of all irrelevant material. The book 
is an exceedingly valuable one, and represents 
an amount of study tind experience which is 
only appreciated after a careful reading.— 
Medical Hecord. 



Physicians' Interpreter. 

In Four Languages (English, French, German, and Italian). 
Specially Arranged for Diagnosis by M. von V. 



The object of this little work is to meet a need often keenly felt by the 
busy, physician, namely, the need of some quick and reliable method of com- 
municating intelligibly with patients of those nationalites and languages unfa- 
miliar to the practitioner. The plan of the book is a systematic arrangement of 
questions upon the various branches of Practical Medicine, and each question is 
so worded that the only answer required of the patient is merely Yes or No. 
The questions are all numbered, and a complete Index renders them always 
available for quick reference. The book is written by one who is well versed in 
English, French, German, and Italian, being an excellent teacher in all those 
languages, and who lias also bad considerable hospital experience. Bound in 
Full Russia Leather, for carrying in the pocket. Size, 5x23 inches. 206 pages. 

Price, post-paid, in the United States and Canada, $1.00, net; in Great 
Britain, 6s. ; in France, 6 fr. 20. 



Many other books of the same sort, with 
more extensive vocabularies, bave been pub- 
lished, but. from their size, and from their 
being usually devoted to equivalents in Eng 

ii-i I one other language only, they have 

not had the advantage \\ hicb i- pre-eminent in 

this — convenience, it Is hands elj printed, 

and bound In flexible red leather In the form 
of a diary. It would scarcely make Itself felt 
in one's hip-pocket, anil would insuie it- 
hearer against any ordinary conversational 



difficulty m dealing with foreign-speaking 
people, who are constantly coming Into our 
eit., hospitals.- New Fork MedicalJournal. 

This little volume is one of. tin- must infze- 

ei'ins aids to the physician which we have 
seen. We heartily commend the boob to any 

i who, being without a knowledge of the 

foreign languages, iw obliged t<> treat those 
who do not know our own language.— Bt. JLouit 
Courii ' 0/ Medicine. 



(13) 



Medical Publications of The F. A. Davis Co.. Philadelphia. 

The Medical Bulletin Visiting-List or 
Physicians' Call Record. 

arranged upon an original and convenient monthly and weekly 
Plan for the Daily Recording of Professional Visits. 



Frequent Rewriting of Names Unnecessary. 

THIS Visiting-List is arranged so that the names of patients need be written 
birt once a month instead of four times a month, as in the old-style lists. 
By means of a new feature, a simple device consisting of stub or half 
leaves in the form of inserts, the first week's visits are recorded in the usual 
way, and the second week's visits are begun by simply turning over the half-leaf 
without the necessity of rewriting the patients' names. This very easily under- 
stood process is repeated until the month is ended and the record has been kept 
complete in every detail of visit, charge, credit, etc., and the labor and time 
of entering and transferring names at least three times in the month has been 
saved. There are no intricate rulings ; not the least amount of time can be lost 
in comprehending the plan, for it is acquired at a glance. 

THE THREE DIFFERENT STYLES MADE. 

The No. 1 Style of this List provides space for the daily record of seventy 
different names each month for a year ; for physicians who prefer a List that will 
accommodate a larger practice we have made a No. 2 Style, which provides 
space for the daily record of 105 different names each month for a year, and for 
physicians who mayjprefer a Pocket Record-Book of less thickness than either of 
these styles we have made a No. 3 Style, in which "The Blanks for the Record- 
ing of Visits in " have been made into removable sections. These sections are 
very thin, and are made up so as to answer in full the demand of the largest 
practice, each section providing ample space for the daily record of 210 dif- 
ferent names for two months ; or 105 different names daily each month for four 
months ; or seventy different names daily each month for six months. Six sets 
of these sections go with each copy of No. 3 Style. 

SPECIAL FEATURES NOT FOUND IN ANY OTHER LIST. 

In this No. 3 Style the printed matter, and such matter as the blank 
forms for Addresses of Patients, Obstetric Record, Vaccination Record, 
Cash Account, Birth and Death Records, etc., are fastened permanently in the 
back of the book, thus reducing its thickness. The addition of one of these 
removable sections does not increase the thickness more than an eighth of an inch. 
This brings the book into such a small compass that no one can object to it on 
account of its thickness, as its bulk is very much less than that of any visiting- 
list ever published. Every physician will at once understand that as soon as a 
section is full it can be taken out, filed away, and another inserted without the 
least inconvenience or trouble. Extra or additional sections will be furnished at 
any time for 15 cents each or $1.75 per dozen. This Visiting-List contains calen- 
dars, valuable miscellaneous data, important tables, and other useful printed 
matter usually placed in Physicians' Visiting-Lists. 

Physicians of many years' standing and with large practices pronounce it 
the Best List they have ever seen. It is handsomely bound in fine, strong 
leather, with flap, including a pocket for loose memoranda, etc., and is furnished 
with a Dixon lead-pencil of excellent quality and finish. It is compact and con- 
venient for carrying in the pocket. Size, 4x6^ inches. 

insr t:k:e2.:e::e: styles. net pricks. 

No. 1. Regular size, to accommodate 70 patients daily each month for one year, . . . $1.25 
No. 2. Large size, to accommodate 105 patients daily each month for one year, . . . . SI. 50 
No. 3. In which the " Blanks for Recording Visits in " are in removable sections, . . . SSI. 75 

Special Edition for Great Britain, without printed matter, 4s. 6d. 

N. B.—The Recording of Visits in this List may be Commenced at any time during the Year. 
(14) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



3IICHJEWER 



Hand-Book of Eclampsia; 

By E. Michener, M.D. ; J. H. 
Thompson, M.D. ; S. Stebbins, M.D. 



OH, NOTES AND CASES 

OF PCERPERAI. 

CONVULSIONS. 

Sttjbbs, M.D. ; R. B. Ewing, M.D. ; B. 
16nio. Cloth. 



Price, 60 cents, net ; in Great Britain, 4s. 6d. ; Prance, i fr. 20. 



WISSJEN 
A MANUAL OF INSTRUCTION FOR GIVING 

Swedish Movement $ Massage Treatment 

By Prop. Hartvig Nissen, late Director of the Swedish Health Institute, 
Washington, D. C. ; late Instructor in Physical Culture and Gymnastics at the 
Johns Hopkins University, Baltimore, Met. ; Instructor of Swedish and German 
Gymnastics at Harvard University's Summer School, 1891, etc., etc. 

This excellent little volume treats this very important subject in a practical 
manner. Full instructions are given regarding the mode of applying the Swedish 
Movement and Massage Treatment i various diseases and conditions of the 
human system with the greatest degree >f effectiveness. This book is indispens- 
able to every physician'who wishes to k ;ow how to use these valuable handmaids 
of medicine. 

Illustrated with 29 Original Wood-Engravings. In one 12mo volume of 
128 Pages. Neatly bound in Cloth. 

Price, post-paid, in the United States and Canada, $1.00, net; in Great 
Britain, 6s. ; in Prance, 6 fr. 20. 



This manual is valuable to the practitioner, 
as it contains a terse description of a subject 
but too little understood in this country. . . 
The book is got up very creditably. — N. Y. 
Med. Journal. 

The present volume is a modest account of 
the application of the Swedish Movement and 
ige Treatment, in which the technique 



of the various procedures are clearly stated as 
well as illustrated in a very excellent manner. 
— North American Practit'io?ier. 

This attractive little book presents the sub- 
ject in a very practical shape, and makes it 
possible for every physician to understand at 
least how it is applied, if it does not give him 
dexterity in the art of its application.— Chicago 
Med. Times. 



By the Same Author 

A B C of the Swedish System of 
Educational Gymnastics. 

A Practical Hand-Book for Sciiool-Teachers and the Home. 



By Hartvig Nissen. 

The author lias avoided the use of difficult scientific terms, and made it 
as popular and plain as possible. 

The fullest instructions and commands are given for each exercise, and 
Seventy-seven Excellent Engravings illustrate them and add greatly to the practical 
value of the book. 

It is complete in one neat, small 12mo volume of about 12.1 I'a-cs, and 
may be conveniently carried in the pocket. Bound in Extra Flexible Cloth. 

Price, post-paid, in United States and Canada, 75 Cents, net ; in Great 
Britain, is. ; in France, 4 fr. 



This is one of the books wliicli il N a delight 
to mil ice, "ii account of it- sterling; wort h and 

practical \\t\\\\\. — Kilifii! imial Mmithljl, At- 
lanta, Ga. 

Wo wish this little h'">u were placed In the 
hands of every teacher, and the practice of its 

exercises enforced upon every child of the 
Schools "I every State as well as in lioston.— 
American Lancet. 



The most Intelligent and complete gymnastic 
primer ever published. It lsperfectl> simple, 
and am child will be able to comprehend it. 
Its Illustrations of the different movements 
of the body explain themselves. — Tfte Pacific 
/:, cord oj Med. and Surgery. 

Tin- small volume is useful for physicians, 
students, and :'ii who may be interested in 
public health.— Med. Bulletin. 



(15) 



Medical Publications of The F. A. Davis Co., Philadelphia. 

Physician's All-Requisite Time- and Labor- 
Saving Account-Book. 

Being a Ledger and Account-Book for Physicians' Use, Meeting 
all the Requirements of the Law and Courts. 



Designed by William A. Seibert, M.D , of Easton, Pa. 

Probably no class of people lose more nianey through carelessly kept 
accounts and overlooked or neglected bills than physicians. Often detained at 
the bedside of the sick until late at night, or deprived of even a modicum of rest, 
it is with great difficulty that he spares the time or puts himself in condition to 
give the same care to his own financial interests that a merchant, a lawyer, or 
even a farmer devotes. It is then plainly apparent that a system of bookkeeping 
and accounts that, without sacrificing accuracy, but, on the other hand, ensuring 
it, at the same time relieves the keeping of a physician's book of half their 
complexity and two-thirds the labor, is a convenience which will be eagerly 
welcomed by thousands of overworked physicians. Such a system has at last 
been devised, and we take pleasure in offering it to the profession in the form ot 
The Physician's All-Requisite Time- and Labor- Saving Account-Book. 

There is no exaggeration in stating that this Account-Book and Ledger 
reduces the labor of keeping your accounts more than one -half, and at the same 
time secures the greatest degree of accuracy. We may mention a few of the 
superior advantages of The Physician's All-Requisite Time- and Labor- Saving 
Account-Book, as follows : — 



First — Will meet all the requirements 

of the law and courts. 
Second— Self-explanatory ; no cipher 

code. 
Third — Its completeness without sacri- 
ficing anything. 
Fourth — No posting ; one entry only. 
Fifth — Universal ; can be commenced at 

any time of the year, and can be 

continued indefinitely until every 

account is filled. 
Sixth — Absolutely no waste of space. 
Seventh — One person must needs be 

sick every day of the year to fill 

his account, or might be ten years 

about it and require no more than 

the space for one account in this 

ledger. 
Eighth— Double the number and many 

times more than the number of ac- 

To all physicians desiring a quick, accurate, and comprehensive method of 
keeping their accounts, we can safely say that no book as suitable as this one has 
ever been devised. A descriptive circular showing the plan of the book will be 
sent on application. 

NET PRICES, SHIPPING EXPENSES PREPAID. 

No. 1. 300 Pages, for 900 Accounts per Year, 

Size 10x12, Bound in # -Russia, Raised inu. s, 

Back Bands, Cloth Sides, , . . $5.00 
No. 2. 600 Pages, for 1800 Accounts per Year, 

Size 10x12, Bound in ^ -Russia, Raised 

Back-Bands, Cloth Sides, . . . 8.00 8.80 42s. 

(16) 



counts in any similar book ; the 
300-page book contains space for 
900 accounts, and the 600-page 
book contains space for 1800 ac- 
counts. 

Ninth— There are no smaller spaces. 

Tenth — Compact without sacrificing 
completeness ; every account com- 
plete on same page — a decided ad- 
vantage and recommendation. 

Eleventh — Uniform size of leaves. 

Twelfth — The statement of the most 
complicated account is at once be- 
fore you at any time of month or 
year — in other words, the account 
itself as it stands is its simplest 
statement. 

Thirteenth — No transferring of accounts, 
balances, etc. 



Canada 
(dutv paid). 

$5.50 



(Jreat 
Britain. 



28s. 



France. 

30 fr. 30. 



49 fr. 40 



Medical Publications of The F. A. Davis Co., Philadelphia. 
PRICE and EAGLETON 

Three Charts of the IMervo-Uascular System. 

Part I. — The Nerves. Part II. — The Arteries. 
Part III. — The Veins. 

A New Edition, Revised and Perfected. Arranged by W. Henry Price, 
M.D., and S. Potts Eagleton, M.D. Endorsed by leading anatomists. Clearly 
and beautifully printed upon extra durable paper. 

PART I. The Nerves — Gives in a clear form not only the Cranial and Spinal Nerves, show- 
ing the formation of the different Plexuses and their branches, but alio the complete 
distribution of the Sympathetic Neeves. 

PART II. The Arteries. — Gives a unique grouping of the Arterial system, showing the 
divisions and subdivisions of all th6 vessels, beginning from the heart and tracing their 
continuous distribution to the periphery, and showing at a glance the terminal 
branches of each artery. 

PART III. The Veins.— Shows how the blood from the periphery of the body is gradually 
collected by the larger veins, and these coalescing forming still larger vessels, until they 
finally trace themselves into the Right Auricle of the heart. 

It is therefore readily seen that "The Nervo-Vascular System of Charts " 
offers the following superior advantages : — 

1. It is the only arrangement which combines the Three Systems, and yet 
each is perfect and distinct in itself. 

2. It is the only instance of the Cranial, Spinal, and Sympathetic Nervous 
Systems being represented on one chart. 

3. From its neat size and clear type, and being printed only upon one side, 
it may be tacked up in any convenient place, and is always ready for freshening 
up the memory and reviewing for examination. 

Price, post-paid, in United States and Canada, 50 cents, net, complete ; in 
Great Britain, 3s. 6d. ; in France, 3 fr. 60. 



For the student of anatomy there can pos- 
sibly be no more concise way of acquiring a 
knowledge of the nerves, veins, and arteries 
of the human system. It presents at a glance 
their trunks and branches in the great divis- 
ions of the body. It will save a world of tedi- 
ous reading, and will impress itself on the 
mind as no ordinary vade mecum, even, could. 



Its price is nominal and its value inestimable. 
No student should be without it.— Pacific 
Record of Medicine and Surgery. 

These are three admirably arranged charts 
for the use of students, to assist in memor- 
izing their anatomical sudics. — Buffalo Med. 
and Sura. Jour. 



PUJRDY 

Diabetes: Its Cause, Symptoms $ Treatment 

By Chas. W. Purdt, M.D. (Queen's University), Honorary Fellow of the 
Royal College of Physicians and Surgeons of Kingston ; Member of the College 
of Physicians and Surgeons of Ontario ; Author of "Bright's Disease; and Allied 
Affections of the Kidneys ;" Member of the Association of American Physicians ; 
Member of the American Medical Association ; Member of the Chicago Academy 
of Sciences, etc. 

Contents. — Section I. Historical, Geographical, and Climatological Con- 
siderations of Diabetes Mellitus. II. Physiological and Pathological Considera- 
tions of Diabetes Mellitus III. Etiology of^Diabetes Mellitus. IV. Morbid 
Anatomy of Diabetes Mellitus. V. Symptomatology of Diabetes Mellitus. VI. 
Treatment of Diabetes Mellitus. VII. Clinical Illustrations of Diabetes Mellitus. 
VIII. Diabetes Insipidus ; Ribiioirraphy. 

!2mo. Dark Blue Extra Cloth. Nearly 200 pages. With Clinical Illus- 
trations. No. S in the Physicians' and Studi /its' V,'. ady-JKeference Series. 

Price, post-paid, in the United States and Canada, $1.25, net; in Great 
Britain, 6s. 6d. ; in France, 7 fr. 75. 

This will prove a most entertaining as well 
as most interesting treatise upon a disease 
which frequently Falls to the lot of every 
practitioner. The work has been written ^ Ith 
a special view of bringing out the features of 
tin- disease as it occurs 6 the United States. 
The author has very judiciously arranged the 
little volume, and it will offer many pleasant 
attractions to the practitioner.— Nashville 
Journal of Medicine and Surgery, 

While many monographs have been pub- 



lished 


which have dealt with the subject or 


,i al •-' 


s, we know of none which so thoroughly 


mil.- i|> 


rs its relations to the geographical 


l-'illll il 


.us which exist in the United States. 




ch is more complete in Its summarj <>r 


the sm 


tptomatology and treatment "i this 


affectii 


n. A number of tables, showing the 


percen 


Bgeof Bugar In a very large number of 


alcohol 


e beverages, :i<Ms very considerably u> 


the \;ii 


ic of the work.— Medical News. 



Medical Publications of The F. A. Davis Co., Philadelphia. 
BE3IONDINO 

History of Circumcision. 

From the Earliest Times to the Present. Moral and Physical 
Reasons for its Performance ; with a History of Eunuchism, 
Hermaphrodism, etc., and of the Different Opera- 
tions Practiced upon the Prepuce. 
By P. C. Remondino. M.D. (Jefferson), Member of the American Med- 
ical Association; of the American Public Health Association; Vice- 
President of California State Medical Society and of Southern California 
Medical Society, etc. 

In one neat 12mo volume of 346 pages. Handsomely bound in Extra 
Dark-Blue Cloth, and illustrated with two fine wood-engravings, showing 
the two principal modes of Circumcision in ancient times. No. 11 in the 
Physicians' 1 and Students' 1 Ready -Reference Series. 

Price, post-paid, in United States and Canada, $1.25, net; in Great Britain, 

6s. 6d. ; in France, 7 fr. 75. 
A Popular Edition (unabridged), bound in Paper Covers, is also issued. Price, 

50 Cents, net ; in Great Britain, 3s. ; in France, 3 fr. 60. 
Eveiy physician should read this book; lie will there find, in a 
condensed and s}'stematized form, what there is known concerning 
Circumcision. The book deals with simple facts, and it is not a disserta- 
tion on theories. It deals, in plain, pointed language, with the relation 
that the prepuce bears to physical degeneracy and disease, bases all its 
utterances on what has occurred and on what is known. The author has 
here gathered from every source the material for his subject, and the 
deductions are unmistakable. 



This is a very full and readable book. To 
the reader who wishes to know all about 
the antiquity of the operation, with the views 
pro and con of the right of this appendage to 
exist, its advantages, dangers, etc., this is the 
book. — The Southern Clinic. 

The operative chapter wiU be particu- 
larly useful and interesting to physicians, as 
it contains a careful and impartial review of 
all the operative procedures, from the most 



simple to the most elaborate, paying particular 
attention to the subject of after-dressings It 
is a very interesting and instructive work, and 
should be read verv liberally by the profes- 
sion.— The Med. Brief. 

The author's views in regard to circum- 
cision, its necessity, and its results, are well 
founded, and its performance as a prophylactic 
measure is well established. — Columbus Med. 
Journal. 



By the Same Author 

The Mediterranean Shores of America. 

Southern California: Its Climatic, Physical, and Meteorological 
Conditions. 
By P. C. Remondino, M.D. (Jefferson), etc. 

Complete in one handsomely printed Octavo volume of nearly 175 
pages, with 45 appropriate illustrations and 2 finely executed maps of 
the region, showing altitudes, ocean currents, etc. Bound in Extra Cloth. 

Price, post-paid, in United States and Canada, $1.25, net ; in Great Britain, 

6s. 6d. ; in France, 7 fr. 75. 
Cheaper Edition (unabridged), bound in Paper, post-paid, in United States and 

Canada, 75 Cents, net ; in Great Britain, 4s. ; in France, 5 fr. 
Italy, of the Old World, does not excel nor even approach this region 
in point of salubrity of climate and all-around healthfulness of environ- 
ment. This book fully describes and discusses this wonderfully charming 
county. The medical profession, who have long desired a trustworthy 
treatise of true scientific value on this celebrated region, will find in this 
volume a satisfactory response to this long-felt and oft-expressed wish. 

(18) 



a 



i _ Medical Publications of The F. A. JDavis Co., Pluiaaetpiua. 
ROHE 

Text-Book of Hygiene. 

A Comprehensive Treatise on the Principles and Practice of 
Preventive Medicine prom an American Stand-point. 

By George H. Rohe, M.D., Professor of Obstetrics and Hygiene in 
the College of Physicians and Surgeons, Baltimore ; Member of the 
American Public Health Association, etc. 

Every Sanitarian should have Robe's " Text-Book of Hj^giene " as a 
work of reference. 

Second Edition, thoroughly revised and largely rewritten, with 
many illustrations and valuable tables. In one handsome Royal Octavo 
volume of over 400 pages, bound in Extra Cloth. 

Price, post-paid, in United States, $2.50, net ; Canada (duty paid), $2.75, 
net ; Great Britain, Hs. ; France, 16 fr. 20. 

One prominent feature is that there are no H improvement over the first, all of the matter 



superfluous words ; every sentence is direct 
to the point sought. It is, therefore, easy 
reading, and conveys very much information 
in little space. — The Pacific Record of Medi- 
cine arid Surgery. 

It is unquestionably a work that should be 
in the hands of every physician in the country, 
and medical students will find it a most excel- 
lent and valuable text-book.— The Southern 
-Practitioner. 

The first edition was rapidly exhausted, and 
the book justly became an authority to physi- 
cians and sanitary officers, and a text-book 
very generally adopted in the colleges through- 
out America. The second edition is a great 



being thoroughly revised, much of it being 
rewritten, and many additions being made. 
The size of the book is increased one hundred 
pages. The book has the original recommenda- 
tion of being a handsomely-bound, clearly- 
printed octavo volume, profusely illustrated 
with reliable references for every branch of 
the subject matter.— Medical Record 

•The wonder is how Professor Rohe has made 
the book so readable and entertaining with so 
much matter necessarily condensed. Alto- 
gether, the manual is a good exponent of 
hygiene and sanitary science from the present 
American stand-point, and will repay with 
pleasure and profit any time that may be given 
to its perusal.— University Medical Magazine. 



By the Same Author 

A Practical Manual of Diseases 
of the Skin. 

By George H. Rohe, M.D., Professor of Materia Medica, Thera- 
peutics, and Hygiene, and formerly Professor of Dermatology in the 
College of Physicians and Surgeons, Baltimore, etc., assisted by J. 
Williams Lord, A.B., M.D., Lecturer on Dermatology and Bandaging 
in the College of Physicians and Surgeons; Assistant Physician to the 
Skin Department in the Dispensary of Johns Hopkins Hospital. 

In one neat 12mo volume of over 300 pages, bound in Extra Dark-Blue 
Cloth. No. 13 in the Physicians' and Students' Ready-Reference Series. 

Price, post-paid, in the United States and Canada, $1.25, net; in Great 
Britain, 6s. 6d. ; in France, 7 fr. 75. 

The practical character of this work makes it specially desirable 
for the use of students and general practitioners. 

The nearly one hundred (100) reliable and carefully prepared For- 
mula' at the end of the volume add not a little to its practical value. 

All the various forms of skin diseases, from Acne to Zoster (alpha- 
betically speaking), are succinctly yel amply treated of, and the arrange- 
ment of the book, with its excellent index and unusually full table <>f 
contents, »oes to make up a truly satisfactory volume for ready reference 
in daily practice. 

(19) 



Medical Publications of TJie F. A. Davis Co., Philadelphia. 



Principles of Surgery. 

By N. Senn, M.D., Ph.D., Professor of Practice of Surgery and Clinical Surgery in 
Rush Medical College, Chicago, 111.; Professor of Surgery in the Chicago Polyclinic; At- 
tending Surgeon to the Milwaukee Hospital ; Consulting Surgeon to the Milwaukee County 
Hospital and to the Milwaukee County Insane Asylum. 

This work, by one of America's greatest surgeons, is thoroughly complete ; its 
clearness and brevity of statement are among its conspicuous merits." The author's long, 
able, and conscientious researches in every direction in this important field are a guarantee, 
of unusual trustworthiness, that every branch of the subject is treated authoritatively, and in 
such a manner as to bring the greatest gain in knowledge to the practitioner and student. 

In one handsome Royal Octavo volume, with 109 fiue Wood-Engravings and 634 
pages. 

United States. Canada (duty paid). Great Britain. France 

Price in Cloth, $150, Net $5.00, Net 24s. 6i 27 fr. 20 

" Sheep or |-Russia, 5.50 " 6.10 " 30s. 33 fr. 10 

Stephen Smith, M.D., Frofessor of Clin- 
ical Surgery Medical Department University 
of the City of New York, writes : — " I have 
examined the work with great satisfaction, 
and regard it as a most valuable addition to 
American surgical literature. There has long 
been great, need of a work on the principles of 
surgery which would fully illustrate the pres- 
ent advanced state of knowledge of the various 
subjects embraced in this volume. The work 
seems to me to meet this want admirably." 



LEWIS A. Sayre, M.D., Professor Ortho- 
paedic Surgery Bellevue Hospital Medical 
College, New Vork, writes :— " My Dear Doctor 
Senn : Your very valuable work on surgery, 
sent to me some time since, I have studied 
with great, satisfaction and improvement. 1 
congratulate you most heartily on having pro- 
duced the most classical and practical work on 
surgery yet published." 

Frank J. Ltjtz, M.D., St. Louis, Mo., says : 
— " It, seems incredible that those who pretend 
to teach have done without such a guide 
before, and I do not understand how our stu- 
dents succeeded in mastering the principles of 
modern surgery by attempting to read our 
obsolete text-hooks. American surgery should 
feel proud of the production, and the present 
generation of surgeons owe you a debt of 
gratitude." 

Wm. Osler, M.D., The Johns Hopkins Hos- 
pital, Baltimore, says: — "You certainly have 
covered the ground' thoroughly and well, and 
with a thoroughness I do not know of in any 
similar work. I should think it would prove 
a great boon to the students and also to very 
many teachers." 

The work is systematic and compact, without 
a fact omitted or a sentence too much, and it 
not only makes instructive but fascinating 
reading. A conspicuous merit of Senn's work 
is his method, his persistent and tireless search 
through original investigations for additions 



to knowledge, and the practical character of 
his discoveries. — The Iteview of Insanity and 
Nervous Diseases. 

Every chapter is a mine of information con- 
taining all the recent advances on the subjects 
presented in such a systematic, instructive, 
and entertaining style that the reader will not 
willingly lay it aside, but will read and re-read 
with pleasure and profit.— Kansas Medical 
Journal. 

After perusing this work on several different 
occasions, we have come to the conclusion that 
it is a remarkable work, by a man of unusual 
ability. The author seems to have had a very 
large personal experience, which is freely made 
use of in the text, besides which he is familiar 
with almost all that has been written in Eng- 
lish and German on the above topics. — Tiie 
Canada Medical Record. 

The work is exceedingly practical, as the 
chapters on the treatment of the various con- 
ditions considered are based on sound deduc- 
tions, are complete, and easily carried out by 
any painstaking surgeon. All in all, the book 
is a most excellent one, and deserves a place in 
every well-selected library.— Medical Record. 

It will prove exceedingly valuable in the 
diffusion of more thorough knowledge of the 
subject-matter among English-speaking sur- 
geons. As in the case of all bis work, he bas 
done this in a truly admirable manner. The 
book throughout is worthy of the highest 
praise. It should be adopted as a text-book 
in all of our schools.— University Medical 
Magazine. 

The principles of surgery, as expounded by 
Dr. Senn, are such as to place the student in 
the independent position of evolving from 
them methods of treatment ; the master of the 
principles readily becomes equally a master 
of practice. And this, of course, is really the 
whole purpose of the volume.— Weekly Med- 
ical Review. 



HAY FEVER 



8 A JO ITS 

And Its Successful Treatment toy Superficial 
Organic Alteration of tlie Nasal 

mucous Membrane. 

By Charles E. Sajotts, M.D., formerly Lecturer on Rhinology and Laryngology in 
Jefferson Medical College ; Cuief Editor of the Annual of the Universal Medical Sciences, 
etc. With 13 Engravings on Wood. 103 pages. 12mo. Bound in Cloth, Beveled Edges. 

Price, post-paid, in the United States and Canada, $1.00, net ; in Great 
Britain, 6s. ; in Prance, 6 fr. 20. 

(20) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



SHOEMAKER 

Heredity, Health, and Personal Beauty. 

Including the Selection of the Best Cosmetics for the Skin, Hair, 
Nails, and all Parts Relating to the Body. 

By John V. Shoemaker, A M., M.D., Professor of Materia Medica, Phar- 
macology, Therapeutics, and Clinical Medicine, and Clinical Professor of Diseases 
of the Skin in the Medico-Chirurgical College of Philadelphia; Physician to the 
Medico-Chirurgical Hospital, etc., etc. 

The health of the skin and hair, and how to promote them, are discussed; 
the treatment of the nails; the subjects of ventilation, food, clothing, warmth, 
bathing; the circulation of the blood, digestion, ventilation; in fact, "all that in 
daily life conduces to the well-being of the body and refinement is duly enlarged 
upon. To these stores of popular information is added a list of the best medicated 
soaps and toilet soaps, and a whole chapter of the work is devoted to household 
remedies. The work is largely suggestive, and gives wise and timely advice as 
to when a physician should be consulted. This is just the book to place on the 
waiting-room table of every physician, and a work that will prove useful in the hands 
of your patients. 

Complete in one handsome Royal Octavo volume of 425 pages, beautifully 
and clearly printed, and bound in Extra Cloth, Beveled Edges, with side and 
back gilt stamps and in Half-Morocco Gilt Top. 

Price, in United States, post-paid, Cloth, $2.50; Half-Morocco, $3.50, 
net. Canada (duty paid), Cloth, $2.75; Half-Morocco, $3.90, net. 
Great Britain, Cloth, 14s. ; Half-Morocco, 19s. 6d. France, Cloth, 
15 fr.j Half-Morocco, 22 fr. 



The book reads not like the fulfillment of a 
task, but like the researches ami observations 
of one thoroughly in love with his subject, 
fully appreciating its importance, and writing 
for "the pleasure he experiences in it. The 
work is very comprehensive and complete in 
its scope.— Medical World. 

The book before us is a most remarkable 
production and a most entertaining one. The 
book is equally well adapted for the laity or 
the profession. It tells us how to be healthy, 
happy, and as beautiful as possible. We can't ! 
review this book; it is different from anything 
we have ever read. It runs like a novel, and i 
will be perused until finished with pleasure [ 
and profit. Buy it, read it, and be surprised, | 



pleased, and improved.— The Southern Clinic 
This book is written primarily for the laity, 
but will prove of interest to the physician as 
well. Though the author goes to some extent 
into technicalities, he confines himself to the 
use of good, plain English, and in that respect 
sets a notable example to many other writers 
on similar subjects. Furthermore, the book 
is written from a thoroughly American stand- 
point.— Medical Record. 

This is an exceedingly interesting book, 
both scientific and practical in character, in- 
tended for both professional and lay readers. 
The book is well written and presented in ad- 
mirable form by the publisher. — Canadian 
Practitioner. 



SHOEMAKER 



Ointments and Oleates 



Especially in Diseases 
of the Skin. 

By John V. Shoemaker, A.M., M.D., Professor of Materia Medica, Phar- 
macology, Therapeutics, and Clinical Medicine, and Clinical Professor of Diseases 
of the Skin in the Medico-Chirurgical College of Philadelphia, etc., etc. 

The author concisely concludes his preface as follows: "The reader may 
thus obtain a conspectus of the whole subject of inunction as it exists to day in 
the civilized world. In all cases the mode of preparation is given, and the thera- 
peutical application described seriatim, in so far as may be done without needless 
repetition ." 

Second Edition, revised and enlarged. 298 pages. 12mo. Neatly bound 
in Dark-Blue Cloth. No. 6 in the Physicians' and Students' Ready Reft r< nee 8t Hi 8. 

Price, post-paid, in the United States and Canada, $1.50, net; in Great 
Britain, 8s. 6i ; in France, 9 fr. 35. 

It is invaluable a.« a ready reference when 

ointments or oleates are to tie 086(1 and i- 

servtceable to both druggist and ph; 
Canada Medical Record. 

To the physician who feels uncertain as U> 



the beel form In which to proscribe medicines 
by way of the ekin the booh will provevalu- 
able, owing to the many prescriptions and 
formula which dot its pages, while 1 1 > * ■ eopions 
Index at tht back materially aids in making 
the l»>"k a useful one.— Medical Sews. 



(21) 



Medical Publications of The F. A. Davis Co., Philadelphia. 
SMOB3IAKER 

Materia JVIedica and Therapeutics. 

With Espectal Reference to the Clinical Application of Drugs. 
Being the Second and Last Volume of a Treatise on Materia 
Medica, Pharmacology, and Therapeutics, and an Independent 
Volume upon Drugs. 

By John V. Shoemaker, A.M., M.D., Professor of Materia Medica, 
Pharmacology, Therapeutics, and Clinical Medicine, and Clinical Professor of 
Diseases of the Skin in the Medico-Chirurgical College of Philadelphia; Physician 
to the Medico-Chirurgical Hospital, etc., etc. 

This, the second volume of Shoemaker's "Materia Medica, Pharmacology, 
and Therapeutics," is wholly taken up •with the consideration of drugs, each 
remedy being studied from three points of view, viz. : the Preparations, or Materia 
Medica; the Physiology and Toxicology, or Pharmacology; and, lastly, its 
Therapy. It is thoroughly abreast of the progress of Therapeutic Science, and 
is really an indispensable book to every student and practitioner of medicine. 

Royal Octavo, about 675 pages. Thoroughly and carefully indexed. 

Price, in United States, post-paid, Cloth, $3.50; Sheep, $1.50, net. 
Canada (duty paid), Cloth, $100; Sheep, $5.00, net. Great Brit- 
ain, Cloth, 20s. ; Sheep, 26s. France, Cloth, 22 fr. 40 ; Sheep, 
23 fr. 60- 
The first volume of this work is devoted to Pharmacy, General Pharma- 
cology, and Therapeutics, and remedial agents not properly classed with drugs. 
Royal Octavo, 353 pages. 

Price of Volume I, post-paid, in Untted States, Cloth, $2.50, net; Sheep, 
$3.25, net. Canada, duty paid, Cloth, $2.75, net; Sheep, $3.60, net. 
Great Britain, Cloth, 14s. ; Sheep, 18s. France, Cloth, 16 fr. 30 ; 
Sheep, 20 fr. 20. The volumes are sold separately. 

SHOEMAKER'S TREATISE ON MATER/A MEDICA, PHARMACOLOGY, AND THERA- 
PEUTICS STANDS ALONE. 

(1) Among Materia Medica text-books, in that it includes every officinal drug and every 

preparation contained in the United States Pharmacopoeia. 

(2) In that it is the only work on therapeutics giving the strength, composition, and dosage 

of every officinal preparation. 

(3) In giving the latest investigations with regard to the physiological action of drugs and 

the most recent applications in therapeutics. 

(4) In combining with officinal drugs the most reliable reports of the actions and uses of all 

the noteworthy new remedies, such as acetanilid, antipyrin, bromoform, exalgin, pyok- 
tanin, pyridin, somnal, spermine (Brown-Se'quard), tuberculin (Koch's lymph), sulphonal, 
thiol, urethan, etc., etc. 

(5) As a complete encyclopaedia of modern therapeutics in condensed form, arranged alpha- 

betically for convenience of reference for either physician, dentist, or pharmacist, when 
immediate information is wanted concerning the action, composition, dose, or antidotes 
for any officinal preparation or new remedy. 

(6) In giving the physical characters and chemical formulae of the new remedies, especially 

the recently-introduced antipyretics and analgesics. 

(7) In the fact that it gives special attention to the consideration of the diagnosis and treat- 

ment of poisoning by the more active drugs, both officinal and non-officinal. 

(8) And unrivaled in the number and variety of the prescriptions and practical formulae, 

representing the latest achievements of clinical medicine. 

(9) In that, while summarizing foreign therapeutical literature, it fully recognizes the work 

done in this department by American physicians. It is an epitome of the present state 
of American medical practice, which is universally acknowledged to be the best practice. 

(10) Because it is the most complete, convenient, and compendious work of reference, being, 

in fact, a companion to the United States Pharmacopoeia, a drug-encyclopaedia, and a 
therapeutic hand-book all in one volume. 

The value of the book lies in the fact that II material compressed in so limited a space, 
it contains all that is authentic and trust- ; The book will prove a valuable addition to the 
worthy about the host of new remedies which physician 's library.— Occidental Med. Times. 



have deluged us in the last five years. The 
pages are remarkably free from useless infor- 
mation. The author has done well in following 
the alphabetical order.— N. Y. Med. Record. 
In perusing the pages devoted to the special 
consideration of drugs, their pharmacology, 
physiological action, toxic action, and therapy, 
one is constantly surprised at the amount of 



It is a meritorious work, with many unique 
features. It is richly illustrated by well-tried 
prescriptions showing the practical applica- 
tion of the various drugs discussed. In short, 
this work makes a pretty complete encyclo- 
paedia of the science of therapeutics, conve- 
niently arranged for handy reference.— Med. 
World. 



(22) 



Medical Publications of Tlie F. A. Davis Co., Philadelphia. 
SMITH 

Physiology of the Domestic Animals. 

A Text-Book for Veterinary and Medical Students and Practitioners. 

By Robert Meade Smith, A.M., M.D., Professor of Comparative Physi- 
ology in University of Pennsylvania; Fellow of the College of Physicians and 
Academy of the Natural Sciences, Philadelphia; of American Physiological 
Society; of the American Society of Naturalists, etc. 

This new and important work, the most thoroughly complete in the 
English language on this subject, treats of the physiology of the domestic animals 
in a most comprehensive manner, especial prominence being given to the subject 
of toods and fodders, and the character of the diet for the herbivora under 
different conditions, with a full consideration of their digestive peculiarities. 
Without being overburdened with details, it forms a complete text-book of 
physiology adapted to the use of students and practitioners of both veterinary 
and human medicine. This work has already been adopted as the Text-Book on 
Physiology in the Veterinary Colleges of the United States, Great Britain, and 
Canada. In one Handsome Royal Octavo Volume of over 950 pages, profusely 
illustrated with more than 400 Fine Wood-Engravings and many Colored Plates. 

United States. Canada (duty paid) Great Britain. France. 

Price, Cloth, - - $5.00, Net $5.50, Net 28s. 30 fr. 30 

" Sheep, - - 6.00 " 6.60 " 32s. 36 fr. 20 

full understanding of the text.— Journal oj 
Comparative Medicine and Surgery. 

Veterinary practitioners and .graduates will 
read it with pleasure. Veterinary students 
will readily acquire needed knowledge from 
its pages, and veterinary schools, which would 
be well equipped for the work they aim to 
perform, cannot ignore it as their text-book 
in physiology. — American Veterinary Review. 

Altogether, Professor Smith's " Physiology 
of the Domestic Animals" is a happy produc- 
tion, and will be hailed with delight in both 
the human medical and veterinary medical 
worlds. It should find its place, besides, in all 
agricultural libraries.— Paul Paqttin, M.D., 
VS., in the Weekly Medical Review. 

The author has judiciously made the nutri- 
tive functions the strong point of the work, 
and has devoted special attention to the sub- 
ject of foods and digestion. In looking 
through other sections of the work, it appears 
tousthatajust proportion of space is assigned 
to each, in view of their relative importance 
to the practitioner.— London Lancet. 



A. Liatjtard, M.D., H.F.R.C., V.S., Pro- 
fessor of Anatomy, Operative Surgery, and 
Sanitary Medicine in the American Veterinary 
College, New York, writes: — "I have exam- 
ined the work of Dr. R. M. Smith on the 
'Physiology of the Domestic Animals,' and con- 
sider it one of the best additions to veterinary 
literature that we have had for some time." 

E. M. Reading, A.M., M.D., Professor of 
Physiology in the Chicago Veterinary College, 
writes: — "I have carefully examined the 
'Smith's Physiology,' published by you, and 
like it. It is comprehensive, exhaustive, and 
complete, and is especially adapted to those 
who desire to obtain a full knowledge of the 
principles of physiology, and are not satisfied 
with a mere smattering of the cardinal points." 

Dr. Smith's presentment of his subject is as 
brief as the status of the science permits, and 
to this much-desired conciseness he has added 
an equally welcome clearness of statement. 
The illustrations hi the work are exceedingly 
good, and must prove a valuable aid to the 1 



SOZIJSSKEY 



Medical Symbolism. 



Historical Studies in the Arts 
of Healing and Hygiene. 

By Thomas S. Sozinsket, M.D., Ph.D., Author of "The Culture of 
Beauty," "The Care and Culture of Children," etc. 

12mo. Nearly 200 pages. Neatly bound in Dark-Blue Cloth. Appropri- 
ately illustrated with upward of thirty (30) new Wood-Engravings. No. 9 in the 
Physicians' and Students' Beady -Reference Series. 

Price, post-paid, in United States and Canada, $1.00, net ; Great 
Britain, 6s. ; France, 6 fr. 20. 

He who has not time to more folly study the 
more extended records of the past, will highly 
prize this little hook. Its interesting discourse 

upon the past is full of suggestive thought.— 
American Lancet. 

Like an oa.sis in a dry and dusty deserl of 
medical literature, through which we wearily 
stagger, is this work devoted to medical sym- 
bolism and mythology. As the author aptly 

quotes: "What some light hraines may esteem j 
as foolish toyes, deeper judgments can and 



will value as sound and serious matter."— Can- 
adian Practitioner, 

in the vol ii i ue before us we have an admira- 
ble and successful attempt to set forth in 
order those medical symbols which have come 

down to us. ami to ex plain on hist orieal grounds 

their significance. An astonishing amounl of 
information is contained within the e<>\ era of 

the i k, and every page oi the wort bears 

token oi the painstaking genius and erudite 
mind of the now unhappily deceased author 
—London Lancet. 

I) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



STEWART 



Obstetric Synopsis, 



By John S. Stewart, M.D., formerly Demonstrator of Obstetrics and 
Chief Assistant in the Gynaecological Clinic of the Medico-Chirurgical College 
of Philadelphia: with an introductory note by William S. Stewart, A.M., 
M.D., Professor of Obstetrics and Gynaecology in the Medico-Chirurgical College 
of Philadelphia. 

By students this work will be found particularly useful. It is based upon 
the teachings of such well-known authors as Playfair, Parvin, Lusk, Galabin, 
and Cazeaux and Tarnier, and contains much new and important matter of great 
value to both student and practitioner. 

With 42 Illustrations. 202 pages. 12mo. Handsomely bound in Dark- 
Blue Cloth. No. 1 in the Physicians' and Students' Ready -Reference Series. 

Price, post-paid, in the United States and Canada, $1.00, net ; in Great 
Britain, 6s.; France, 6 fr. 20. 



DeLaskie Midler. M.D., Professor of 
Obstetrics, Rush Medical College, Chicago, 
111., says: — "I have examined the 'Obstetric 

Synopsis.' by John S. Stewart, M.D., and it 
gives me pleasure to characterize the work as 
systematic, concise, perspicuous, and authen- 
tic. Among manuals it is one of the best." 

It is well written, excellently illustrated, 
and fully up to date in every respect. Here 
we rind "all the essentials of Obstetrics in a 
nutshell, Anatomy, Embryology, Physiology, 
Pregnancy, Labor, Puerperal State, and < ib- 
stetric Operations all being carefully and ac- 



■urately described.— Buffalo Medical and 
Surgical Journal. 
It is clear and concise. The chapter on the 



development of the ovum is especially satis- 
factory. The judicious use of bold-faced 
type for headings and italics for important 



statements gives the book a pleasing typo- 
graphical appearance. — Medical Record. 

This volume is done with a masterly hand. 
The scheme is an excellent one. The whole 
is freely anil most admirably illustrated with 
well-drawn, new engravings, and the book is 
of a very convenient size.— St. Louis Medical 
and Surgical Journal. 



ULTZ3IAJnf 

The Neuroses of the Genito-Urinary System 
in the Male. 

With Sterility and Impotence. 

By Dr. R. Ultzmann, Professor of Genito-Urinary Diseases in the Uni- 
versity of Vienna. Translated, with the author's permission, by Gardner W. 
Allen, M.D., Surgeon in the Genito-Urinary Department, Boston Dispensary. 

Full and complete, yet terse and concise, it handles the subject with such 
a vigor of touGh, such a clearness of detail and description, and such a directness 
to the result, that no medical man who once takes it up will be content to lay it 
down until its perusal is complete, — nor will one reading be enough. 

Professor Ultzmann has approached the subject from a somewhat different 
point of view from most surgeons, and this gives a peculiar value to the work. 
It is believed, moreover, that there is no convenient hand-book in English treat- 
ing in a broad manner the Genito-Urinary Neuroses. 

Synopsis op Contents. — First Part — I. Chemical Changes in the Urine in 
Cases of Neuroses. II. Neuroses of the Urinary and of the Sexual Organs, 
classified as : (1) Sensory Neuroses; (2) Motor Neuroses ; (3) Secretory Neuroses. 
Second Part — Sterility and Impotence. The treatment in all cases is described 
clearly and minutely. 

Illustrated. 12mo. Handsomely bound in Dark-Blue Cloth. No. 4. in the 
Physicians' and Students' Ready-Reference Series. 

Price, post-paid, in the United States and Canada, $1.00, net ; in Great 
Britain, 6s. ; in France, 6 fr. 20. 



This book is to be highly recommended, 
owing to it- clearness and brevity. Altogether, 
we do not know of any book of the same size 
which contains so much useful information in 
such a short space.— Medical News. 

It- scope is large, not being confined to the 
one condition, — neurasthenia, — but embracing 
all of the neuroses, motor and sensory, of the 
genitourinary organs in the male. No one 
who has read after Dr. Ultzmann need be re- 



minded of his delightful manner of presenting 
his thoughts, which ever sparkle with original- 
ity and appositeness.— Weekly Med. Review. 

It engenders sound pathological teaching, 
and will aid in no small degree in throwing 
light on the management of many of the dif- 
ficult and more refractory cases of the classes 
to which these essays especially refer.— The 
Medical Age. 



(24) 



Medical Publications of The F. A. Davis Co., Philadelphia. 

SAJXNE 

Diphtheria, Croup: Tracheotomy and 
Intubation. 

From the French of A. Sanne. 



Translated and enlarged by Henry Z. Gill, M.D., LL.D., Late Professor of Surgery 
in Cleveland, Ohio. 

Sanne's work is quoted, directly or indirectly, by every writer since its publication, 
as the highest authority, statistically, theoretically, and practically. The translator, having 
given special study to the subject for many years, has added over fifty pages, including the 
Surgical Anatomy, Intubation, and the recent progress in other branches, making it, 
beyond question, the most complete work extant on the subject of Diphtheria in the 
English language. 

FaciiP" the title-paare is found a very fine Colored Lithograph Plate of the parts con- 
cerned in Tracheotomy. Next follows an illustration 01 a cast of the entire Trachea and 
Bronchi to the third or fourth division, in one piece, taken from a photograph of a case in 
which the cast was expelled during life from a patient sixteen years old. This is the most 
complete cast of any one recorded. 

Over fifty other illustrations of the surgical anatomy of instruments, etc., add to the 
practical value of the work. 

A full Index accompanies the enlarged volume, also a List of Authors, making 
altogether a very handsome illustrated octavo volume of over 680 pages. 



Price, post-paid, Cloth, 
Leather, 



United States. 

$4.00, Net 
5.00 " 



Canada (duty paid). 

$140, Net 
5.50 " 



Great Britain. France. 

22s. 6i 24 fr. 60 
28s. 30 fr. 30 



YOUNG 

Synopsis of Human Anatomy. 

Being a Complete Compend of Anatomy, Including the Anatomy of 
the Viscera, and Numerous Tables. 

By James E. Young, M.D., Instructor in Orthopaedic Surgery and Assistant Demon- 
strator of Surgery, University of Pennsylvania ; Attending Orthopaedic Surgeon, Out- 
Patient Department, University Hospital, etc. 

While the author has prepared this work especially for students, sufficient descriptive 
matter has been added to render it extremely valuable to the busy practitioner, particularly 
the sections on the Viscera, Special Senses, and Surgical Anatomy. 

The work includes a complete account of Osteology, Articulations and Ligaments, 
Muscles, Fascias, Vascular and Nervous Systems, Alimentary, Vocal, and Respiratory and 
Genito-Urinary Apparatus, the Organs of Special Sense, and Surgical Anatomy. 

In addition to a most carefully and accurately prepared text, wherever possible, the 
value of the work has been enhanced by tables to facilitate aud minimize the labor of stu- 
dents in acquiring a thorough knowledge of this Important Bubject. The Bection on the 
teeth has also been especially prepared to meet the requirements of students of dentistry. 

Illustrated with 70 Wbod-EngravingB. 890 pages. 12mo. Bound in Extra Dark- 
Blue Cloth. No. S in live Physicians' and Students' Ready-Rrferencc Srriis. 

Price, post-paid, in the United States and Canada, $1.40, net; in Great 
Britain, 8s. 6d ; in France, 9 fr. 25. 



Every unnecessary word has been excluded, 
oat of regard t<> the very limited time at the 
medical student's disposal, it is also good as 
:i reference-book, as it presents the facte about 
which he wishes to refresh Ms memory In the 
briefest manner consistent with clearness. — 
New York Medical Journal. 

As a companion to the dissecting-table, and 
a convenient reference for the practitioner, it 



hnsa definite Held of usefulness.— 1'ittxlmrtih 

Medical Review, 

The book is much more satisfactory than the 
"remembrances" In rogue, and yet Is not too 
cumbersome to be carried around and read al 
mill moments ■> property which the student 
will readily appreciate. — Weekly Medical 

Itii i< ir. 



(25) 



Medical Publications of The F. A. Davis Co., Philadelphia. 
WITHERSTINE 

The International Pocket Medical Formulary 

Arranged Therapeutically. 

By C. Sumner Withebstine, M.S., M.D., Associate Editor of the 
'Annual of the Universal Medical Sciences;" Visiting Physician of the Home 
for the A<:ed, Germantown, Philadelphia ; Late House-Surgeon Charity Hospital, 

New York. 

More than 1800 formulas from several hundred well-known authorities. 
With an Appendix containing a Posological Tahle, the newer remedies included ; 
Important Incompatibles ; Tables on Dentition and the Pulse ; Table of Drops 
in a Fluidrachm and Doses of Laudanum graduated for age ; Formulae and Doses 
of Hypodermatic Medication, including the newer remedies; Uses of the Hypo- 
dermatic Syringe ; Formulae and Doses for Inhalations, Nasal Douches, Gargles, 
and Eye-washes ; Formulae for Suppositories ; Use of the Thermometer in Dis- 
ease ; Poisons, Antidotes, and Treatment ; Directions for Post-Mortem and 
Medico-Legal Examinations ; Treatment of Asphyxia, Sun-stroke, etc. ; Anti- 
emetic Remedies and Disinfectants ; Obstetrical Table ; Directions for Ligations 
of Arteries ; Urinary Analysis ; Table of Eruptive Fevers ; Motor Points for 
Electrical Treatment, etc. 

This work, the best and most complete of its kind, contains about 275 
printed pages, besides extra blank leaves — the book being interleaved throughout 
— elegantly printed, with red lines, edges, and borders; with illustrations. Bound 
in leather, with side flap. 

It is a handy book of reference, replete with the choicest formulae (over 
1800 in number) of more than six hundred of the most prominent classical writers 
and modern practitioners. 

The remedies given are not only those whose efficiency has stood the test 
of time, but also the newest and latest discoveries in pharmacy and medical 
science, as prescribed and used by the best-known American and foreign modern 
authorities. 

It contains the latest, largest (66 formulae), and most complete collection of 
hypodermatic formulae (including the latest new remedies) ever published, with 
doses and directions for their use in over fifty different diseases and diseased 
conditions. 

Its appendix is brimful of information, invaluable in office work, emergency 
cases, and the daily routine of practice. 

It is a reliable friend to consult when, in a perplexing or obstinate case, the 
usual line of treatment is of no avail. (A hint or a help from the best authorities, 
as to choice of remedies, correct dosage, and the eligible, elegant, and most palat- 
able mode of exhibition of the same.) 

It is compact, elegantly printed and bound, well illustrated, and of conve- 
nient size and shape for the pocket. 

The alphabetical arrangement of the diseases and a thumb-letter index 
render reference rapid and easy. 

Blank leaves, judiciousl}' distributed throughout the book, afford a place to 
record and index favorite formulae. 

As a student, the physician needs it tor study, collateral reading, and for 
recording the favorite prescriptions of his professors, in lecture and clinic; as a 
recent graduate, he needs it as a reference hand-book for daily use in prescribing 
(gargles, nasal douches, inhalations, eye-washes, suppositories, incompatibles, 
poisons, etc.); as an old practitioner, he needs it to refresh his memory on old 
remedies and combinations, and for information concerning newer remedies and 
more modern approved plans of treatment. 

No live, progressive medical man can afford to be without it. 
Price, post-paid, in United States and Canada $2.00, net ; 
Great Britain, lis. 6d. ; France, 12 fr. 40. 

Tt is sometimes important that such preserip- II enough of incompatibilities before commenc- 

tions as have been well established in their | ing practice to avoid writing imompatible and 

usefulness be preserved for reference, and [ dangerous prescriptions. The constant use of 

this little volume serves such a purpose better : such a book by such prescribers would save 

than any other we have seen. — Columbus Med- j the pharmacist much anxiety. — The Drug- 

iealJoumal. I gists 1 Circular. 

To the young physieiun just starting out in I In judicious selection, in accurate nomen. 

practice this little book will prove an accept- clature. in arrangement, and in stvle. it leaves 

able companion.— Omaha Clinic. nothing to be desired. The editor and the 

As long as "combinations" are sought, such publisher are to be con statu lated on the pro- 

a book will be of value, especially to those auction of the very best book of its class.— 

who cannot spare the time required to learn | Pittsburgh Medical Review. 

(26> 



Medical Publications of The F. A. Davis Co., Philadelphia. 

Annual of the Universal Medical Sciences. 

A Yearly Report of the Progress of the General Sanitary 
Sciences Throughout the World. 

Edited by Charles E. Sajocs, M.D., formerly Lecturer on Laryngology 
and Rhinology in Jefferson Medical College, Philadelphia, etc., and Seventy 
Associate Editors, assisted by over Two Hundred Corresponding Editors and 
Collaborators. In Five Royal Octavo Volumes of about 500 pages each, bound 
in Cloth and Half-Russia, Magnificently Illustrated with Chromo-Lithographs, 
Engravings, Maps, Charts, and Diagrams. Being intended to enable any physi- 
cian to possess, at a moderate cost, a complete Contemporary History of Universal 
Medicine, edited by many of America's ablest teachers, and superior in every 
detail of print, paper, binding, etc., a befitting continuation of such great works 
as "Pepper's System of Medicine," "Ashhurst's International Encyclopaedia of 
Surgery," "Buck's Reference Hand-Book of the Medical Sciences." 

SOLD ONLY BY SUBSCRIPTION, OR SENT DIRECT ON RECEIPT OF PRICE, 
SHIPPING EXPENSES PREPAID. 

Subscription Price per Year (including the " SATELLITE " for one year) : 
In United States, Cloth, 5 vols., Royal Octavo, $15.00; Half-Russia, 5 vols., 
Royal Octavo, $20.00. Canada (duty paid), Cloth, $16 50; Half-Russia, 
$22.00. Great Britain, Cloth, £4 7s. ; Half-Russia, £5 15s. France, Cloth, 
93 fr. 95 ; Half-Russia, 121 fr. 35. 
The Satellite of the "Annual of the Universal Medical Sciences." A 
Monthly Review of the most important articles upon the practical branches of 
Medicine appearing in the medical press at large, edited by the Chief Editor of 
the Annual and an able staff. Published in connection with the Annual, and 
for its Subscribers Only. 



Editorial Staff of the Annual of the Universal Medical Sciences. 

CONTRIBUTORS TO SERIES 1888, 1889, 1890, 1891. 

Editor-in-Chief, CHARLES E. SAJOUS, M.D., Philadelphia. 



SENIOR ASSOCIATE EDITORS. 

Agnew, D. Haves, M.D., LL.D.. Philadelphia, 

series of 1X88, 18*9. 
Haldy, J. M.. M.D., Philadelphia, 1891. 
Barton, J. M., A.M., M.D., Philadelphia, 1889, 

1890, 1891. 
Birdsall, W. R., M.D., New York, 1839, 1890, 

1891. 
Brown, P. \V., M.D., Detroit, 1890, 1891. 
Bruen, Edward T.. M.D., Philadelphia, 1889. 
Brush, Kdward X., M.D., Philadelphia, lxso, 

1890. 1891. 
Cohen. J. Solis, M.D., Philadelphia. 1888, 1889, 

1890, 1891. 
Conner, P. s.. M.D., LL.D., Cincinnati, 1888, 

1889, 1801), 181)1. 

Currier, A. P., A.B., M.D., New York, 1889, 

1890, 1891. 

Davidson, CO., M I).. Philadelphia, 1888. 

I LVis. X. S.. A.M., M.D.. LL.D., Chicago, 1888, 

1889, 1890, 1891. 
Delafleld, Francis, M.D., New York. 1888. 
Delavan, l>. P.rvson, M.D., New York. 1888, 

1889, 1890, 1891. 

Draper, P. Winthrop, A.M., M.D., New York, 

1S.SS. 1X80 ]8! 10. 1891. 

Dudley. Kdward C, M.D., Chieairo. ixxx. 
Ernst, Harold 0., A.M.. M.D., Boston, 1889, 

1890, 1891. 

Forbes, William B., M.D., Philadelphia. 1888, 

1889. 1890. 
Garretson, J. E., M.D.. Philadelphia, 1888, 



Gaston, J. McFadden, M.D., Atlanta, 1890, 

1891. 
Gihon. Albert T,., A.M., M.D., Brooklyn, 1888, 

1889. 181)0. 1891. 
Goodeii William. M.D.. Philadelphia, 1888. 

1889. 1890. 
Grav. Landon Carter, M.D., NewYork, 1890, 

1891. 
Griffith, J. P. Crozer, M.D., Philadelphia, 1889, 

18D0, 1891. 
Guilford, S. H., D.D.s., Ph.D.. Philadelphia, 

1888. 
Cuiter.is, John, M.I), Ph,D., Charleston, 1888. 

18X0. 

Hamilton, .lohn P... M.D., LL.D., Washington, 

ISSN. 1880. IS0O. 1801. 
Hare. Ifobirt Amorv. M D., li.Sc , Philadel- 
phia. 1888, 1880. 1800. 1801. 

Ileiirv. Kr.-derirk P.. M.D.. Philadelphia, 1889, 

[890, 1891. 
Holland, J. W., M.D.. Philadelphia. 1888. [889. 
Holt. I.. F.inmett. M.D., New ~i oik. 1880. 1890, 

1891, 
Howell, W. II.. Ph.D.. M.D.. Aim Arbor, 

1889. 1890, 1891. 
Hun, Henry, . ■..!».. Albany, 1889. 1890. 
Hooper. KranLlin II.. M.D.. I'.oxton. 1.800. |80|. 
rngals. E Fletcher, A.M., M.D., Chicago, 1889, 

1800. L891. 
Jaggard, W. W., A.M.. M D., Cbicngn 1890 
Johnston, Chrisioi.her. M.D., 1 Lai t i re, 1888, 

1880. 

Johnston. W. \\\, M.D., Washington, 18x8,1889, 
ItfOO, |891. 



Medical Publications of The F. A. Davis Co., Philadelphia. 



SENIOR ASSOCIATE EDITORS 

(CONTINUED). 

Keating, John M., M.D., Philadelphia, 1889. 
Kelsev, Charles B., M.D., New York, 1888, 1889, 

1890, 1891. 
Jveves, Edward I-.. A.M., M.D., New York, 

"1888, 1889, 1890, 1891. 
Knapp, Philip Coombs, M.D., Boston, 1891. 
Laplace, Ernest, A.M., M.D., Philadelphia, 

D. 1891. 



Lee. John G., M.D., Philadelph 
.D., Pt 

1889, 1890, 1891. 



Leidy, Joseph, M.D., LL. 



hiladelphia, 



Longstaeth, Morris, M.D., Philadelphia, 1888, 

1889, 1890. 

Looinis, Alfred L., M.D., LL.D., New York, 

1888, 1889. 
Lyman, Henry M., A.M., M.D., Chicago, 1888. 
McGuire, Hunter, M.D., LL.D., Richmond, 

1888. 
Manton, Walter P., M.D., F.R.M.S., Detroit, 

1888, 1889, 1890. 1891. 

Martin, H. Newell, M.D., M.A., Dr. Sc, F.R.S., 

Baltimore ""-•' 1089. 
Matas, Rudolph, M.D., New Orleans, 1890, 

1891. 
Mears, J. Ewing, M.D., Philadelphia, 1888, 1889, 

1890, 1891. 

Mills, Charles K.. M.D., Philadelphia, 1888. 
Minot, Chas. Sedgwick, M.D., Boston, 1888, 

1889, 1890, 1891. " 

Montgomery, E. E., M.D., Philadelphia, 1891. 
Morton, Thos. G., M.D., Philadelphia, 1888, 

Munde.'Paul F., M.D., New York, 1888, 1889, 

1890, 1891. 

Oliver, Charles A., A.M., M.D., Philadelphia, 

1889, 1890, 1891. 
Packard, John H., A.M., M.D., Philadelphia, 

1888. 1889, 1890. 1891. 

Parish. Wm. H., M.D., Philadelphia, 1888, 1889, 
1890. 

Parvin, Theophilus, M.D., LL.D., Philadel- 
phia, 1888, 1889. 

Pierce, C. N.. D.D.S., Philadelphia, 1888. 

Pepper, William, M.D., LL.D., Philadelphia, 
1888. 

Ranney, Ambrose L., M.D., New York, 1888, 

1889. 1890. 

Richardson, W. L., M.D., Boston, 1888, 1889. 
Rockwell, A. D., A.M.. M.D., New York. 1891. 
Rohe', Geo. H., M.D.. Baltimore, 1X88, 1889, 1890, 

1891. 
Sajous, Chas. E., M.D., Philadelphia. 1888. 1889, 

1890 1891 
Sayre, Lewis A.. M.D., New York, 1890, 1891. 
Seguin, E. ('., M.D., Providence, 1888, 1889, 

1890. 1891. 

Senn, Nicholas, M.D., Ph.D., Milwaukee, 1888, 

1889. 
Shakspeare. E. O., M.D., Philadelphia, 1888. 
Shattuck, F. O. M.D., Boston, 1890. 
Smith. Allen J., A.M., M.D.. Philadelphia, 1890, 

1891. 
Smith, J. Lewis, M.D., New York, 1888, 1889, 

1890. 1891. 
Spitzka. E. C, M.D., New York. 1888. 
Starr, Louis, M.D., Philadelphia, 1888, 1889, 

1890 1S91 
Stimson. Lewis A., M.D., New York, 1888, 1889, 

1890 1801 
S airgis! F. R, M D., New York. 1888. 
Sudduth, F. X., A.M.. M.D . F.R.M.S., Minne- 
apolis, 1S88. 1889, 1X90, 1X91. 
Thomson, William, M.D., Philadelphia. 1888. 
Thomson, Wm. H., M.D.. New York, 1888. 
Tiffany, L. McLane, A.M., M.D., Baltimore, 

1890. 1891. 
TurnlHill. Chas. S., M.D., Ph.D., Philadelphia, 

1888. 1889, 1890 1891. 
Tyson, James, M.D., Philadelphia, 1888, 1889, 

1890. 
Van Harlingen, Arthur, M.D., Philadelphia, 

1888, 1889, 1890, 1891. 
Vander Veer, Albert, M.D., Pli.D., Albany, 

1890. 
Whittaker. Jas. T., M.D., Cincinnati. 1888. 1889, 

1890, 1891. 
Whittier, E. N., M.D., Boston, 1890, 1891. 
Wilson, James C, A.M., M.D., Philadelphia, 



II Wirgman, Chas., M.D., Philadelphia, 1888. 
l! Witherstine, c. Sumner, M.-5., M.D., Phila- 
delphia, 18S8, 1889. 1890, 1891. 
White, J. William, M.D., Philadelphia, 1889, 

1890, 1891. 
Young, Jas. K., M.D., Philadelphia, 1891. 

JUNIOR ASSOCIATE EDITORS. 

Baldy, J. M., M.D., Philadelphia, 1890. 

Bliss. Arthur Ames, A. M., M.D., Philadelphia, 

1890, 1891. 
Cattell, H. W., M.D.. Philadelphia, 1890, 1891. 
Cerna, David, M.D., PhD.. Philadelphia, 1891. 
Clark, J. Payson, M.D., Boston, 1890. 1891. 
Crandall, F. M., M.D., New York, 1891. 
Cohen, Solomon Solis, A.M., M.D., Philadel- 
. phi a, 1890, 1891, 

Cryer, H. M., M.D., Philadelphia, 1889. 
Deale, Henrv B., M.D.. Washington, 1891. 
Dolley, C. S., M.D., Philadelphia, 1889, 1890, 

1891. 
Dollinger. Julius, M.D., Philadelphia, 1889, 
Dorland, W. A., M.D., Philadelphia. 1891. 

Goodell. W. Constantine, M.D., Philadelphia, 

1888. 1889, 1890. 
Gould. Geo. M..M.D.. Philadelphia, 1889, 1890. 
Greene, E. M.. M.D., Boston, 1891. 
Griffith. .1. P. Crozer, M.D., Philadelphia, 1888. 
Hoag. Junius, M.D., Chicago, 1888. 
Howell, W. H., PhD., B.A., Baltimore, 1888, 

1889. 
Hunt, William, M.D., Philadelphia, 1888, 1889. 



Jackson. Henrv, M.D., Boston, 

Kirk, Edward O, D.D.S.. Philadelphia, 1888. 

Llovd, James Hendrie, M.D., Philadelphia, 

'1888. 
McDonald, Willis G..M.D., Albany, 1890. 
Penrose, Chas. B., M.D.. Philadelphia. 1890. 
Powell. W. M., M.D., Philadelphia, 1889. 1890, 

1891. 
Quinibv, Chas. E., M.D., New York, 1889. 
Sayre, Reginald H., M.D., New York, 1890, 1891. 
Smith, Allen J., A.M., M.D., Philadelphia, 

1889, 1890. 

Vickerv, H. F., M.D., Boston, 1891. 
Warfield. Ridgelv B., M.D., Baltimore, 1891. 
Warner. Frederick M., M.D.. New York, 1891. 
Weed. Charles L., A.M., M.D., Philadelphia, 

1888, 1889. 
Wells. Brooks H., M.D., New York, 1888. 1889, 

1890. 1891. 

Wolff, Lawrence, M.D., Philadelphia, 1890. 
Wyman, Walter, A.M., M.D., Washington, 



ASSISTANTS TO ASSOCIATE 
EDITORS. 

Baruch, S., M.D., New York, 1888. 
Beatty, Franklin T., M.D., Philadelphia. 1888. 
Brown, Dillon, M.D.. New York. 1888. 
Buechler, A. F., M.D.. New York, 1888. 
Burr, Chas. W., M.D., Philadelphia, 1891. 
Cohen. Solomon Solis, M.D., Philadelphia, 

1889. 
Cooke, B. G., M.D., New York, 1888. 
Coolidge, Algernon, Jr., M.D., Boston, 1890. 
Currier, A. F., M.D., New York, 1888. 
Daniels. F. H., A.M., M.D., New York, 1888. 
Deale, Henrv B., M.D., Washington. 1890. 
Eshner, A. A., M.D.. Philadelphia. 1891. 
Gould, George M., M.D., Philadelphia, 1888. 
Grand-n, Egbert H., M.D., New York, 1888, 

1889. 
Greene, E. M.. M D.. Boston. 1890. 
Guitc'ras. G. M., M.D.. Washington, 1890. 
Hance, 1. H., A.M., M.D., New York, 1891. 
Klingensclimidt, C. H. A., M.D., Washington, 

1890. 
Martin. Edward, M.D., Philadelphia, 1891. 
McKee. E. S., M.D., Cincinnati, 1889. 1890, 1891. 
Mvers. F. H., M.D . New York, 1888. 
Packard, F. A., M.D.. Philadelphia, 1890. 
Pritehard. W. B., M.D., New York, 1891. 
Sangree, E. B.. A.M., M.D., Philadelphia, 1890. 
Sears, G. G., M.D.. Boston, 1890. 
Shulz, R. C, M.D., New York, 1891. 
Souwers, Geo. F., M.D., Philadelphia, 1888. 
Taylor, H. L., M.D., Cincinnati. 1X89, 1890. 
Va'nsant. Eugene L.. M.D., Philadelphia, 1888. 



Medical Publications of The F. A. Davis Co., Philadelphia. 



ASSISTANTS TO ASSOCIATE 

EDITORS-(CONTINUED). 

Vickery, H. F., M.D., Boston, 1890. 

Warner, F. M., M.D., New York, 1888, 1889, 

Wells, Brooks H., M.D., New York, 1888. 
Wendt, E. C. M.D., New York, 1888. 
Wilder, W. H, M.D., Cincinnati, 1889. 
Wilson, G. Meigs. M.D., Philadelphia, 1889. 
Wilson, W. R., M.D., Philadelphia, 1891. 

CORRESPONDING STAFF. 
EUROPE. 

Antal, Dr. Gesa v., Puda-Pesth, Hungary. 

Baginsky, Dr. A., Berlin, Germany. 

Baratoux, Dr. J., Paris, Fiance. 

Barker, Mr. A. E. J., London, England. 

Barnes, Dr. Fancourt, London, England. 

Bayer, Dr. Carl, Prague, Austria. 

Bouehut, Dr. F., Paris, France. 

Bourneville, Dr. A., Paris, France. 

Bramwell, Dr. Byron, Edinburgh, Scotland. 

Carter, Mr. William, Liverpool, England. 

Caspari, Dr. G. A., Moscow, Russia. 

Chiralt y Selma, Dr. V., Seville, Spain. 

Cordes, Dr. A., Geneva, Switzerland. 

D'Estrees, Dr. Debout, Contrexeville, France. 

Diakonoff, Dr. P. J., Moscow, Russia. 

Dobrashian, Dr. G. S., Constantinople, Tur- 
key. 

Doleris, Dr. L., Paris France. 

Doutrelepont, Prof., Bonn, Germany. 

Doyon, Dr. H.. Lyons, France. 

Drzewiecki, Dr. Jos., Warsaw, Poland. 

Dubois-Reymond, Prof., Berlin, Germany. 

Ducrey, Dr. A., Naples, Italy. 

Dujardin-Beaumetz, Dr., Paris, France. 

Duke, Dr. Alexander, Dublin, Ireland. 

Eklund, Dr. F., Stockholm, Sweden. 

Fokker, Dr. A. P., Groningen, Holland. 

Fort, Dr. J. A., Paris, France. 

Fournier, Dr. Henri, Paris, France. 

Franks, Dr. Kendal, Dublin, Ireland. 

Fremy. Dr. H., Nice, France. 

Fry, Dr. George, Dublin, Ireland 

Golowina, Dr. A., Varna, Bulgaria. 

Gouguenheim, Dr. A., Paris, France. 

Haig, Dr. A., London, England. 

Hamon, Mr, A., Paris, France. 

H.-vrW M r v., London England 

Harley, Mr. H. R., Nottingham, England. 

Harley, Prof. Geo., London, England. 

Harpe, Dr. de la, Lausanne, Switzerland. 

Harlmann, Prof. Arthur, Berlin, Germany. 

Heitzmann, Dr. J., Vienna, Austria. 

Helferich, Prof., Greifswald, Germany. 

Hewetson, Dr. Bendelack, Leeds, England. 

Hoff, Dr. E. M., Copenhagen, Denmark. 

Humphreys, Dr. F. Rowland, London, Eng- 
land. 

IHingworth, Dr. C. K., Accrington, England. 

Jones, Dr. D. M. de Silva, Lisbon, Portugal. 

Knott, Dr. J. F, Dublin, Ireland. 

Krause, Dr. H., Berlin, Germany. 

Landolt, Dr. E., Paris, France. 

Levison, Dr. J., Copenhagen, Denmark. 

Lutaud, Dr. A., Paris, France. 

Maekay, Dr. W. A., Huelva, Spain. 

Mackowen, Dr. T. C, Capri, Italy. 

Main/he, Dr. L„ Valetta, Malta. 

Massei, Prof. F, Naples, Italy. 

Mendez, Prof. H., Barcelona. Spain. 

Meyer, Dr. E., Naples, Italy. 

?en. Denmark. 
France. 



Meyer Prof. W., Copenii 
Monod, Dr. diaries. Pari 
Montefusco, Prof. A.. Naples, Italy. 
More-Madden, Prof. Thomas, Dublin, Ireland, 
Morel, Dr. J., Ghent, Belgium. 
Mygind, Dr. Holger, Copenhagen. Denmark. 
Mynlieff, Iir. A., Breukelen, Holland. 
Napier, Dr. A. D. Leith. London, England. 
Nicolich, Dr.. Trieste, Austria. 
Oberlander, Dr., Dresden, Germany. 
Obersteiner, Prof., Vienna, Austria. 
Pampoukis, Dr., Athens, Greece. 
Pansoni, Dr., Naples, Italy. 
Parker, Mr. Rushton. Liverpool, England. 
Pel, Prof. p. K., Amsterdam, Holland. 
Pippinskjold, Dr., Helsingfors, Finland. 
Puhdo, Prof. Angel, Madrid, Spain 



Rona, Dr. S., Buda-Pesth, Hungary. 

Rosenbusch, Dr. L., Lvov. Galicia. 

Rossbach, Prof. M. F., Jena, Germany. 

St. Germain, Dr. de, Paris, France. 

Sanger, Prof. M., Leipzig, Germany. 

Santa, Dr. P. de Pietra, Paris, France. 

Schiffers, Prof., Liege, Belgium. 

Schmiegelow, Prof. E., Copenhagen, Den- 
mark. 

Scott, Dr. G. M., Moscow, Russia. 

Simon, Dr. Jules, Paris, France. 

Sollier, Dr. P., Paris, France. 

Solowieff, Dr. A. N., Lipetz, Russia. 

Sota, Prof. R. de la, Seville, Spain. 

Sprimont, Dr Moscow, Russia. 

Stockvis, Prof. B. J., Amsterdam, Holland. 

Szadek, Dr. Carl, Kiew, Russia. 

Tait, Mr. Lawson, Birmingham, England. 

Thiriar, Dr., Brussels, Belgium. 

Trifllettl, Dr., Naples, Italy. 

Tuke, Dr. D. Hack, London, England. 

Ulrik, Dr. Axel, Copenhagen, Denmark. 

Unverricht, Prof., Jena, Germany. 

Van der Mey, Prof. G. H., Amsterdam, Hol- 
land. 

Van Leent, Dr. F., Amsterdam, Holland. 

Van Millingen, Prof. E., Constantinople, Tur- 
key. 

Van Rijnberk, Dr., Amsterdam, Holland. 

Wilson, Dr. George, Leamington, England. 

Wolfenden, Dr. Norris, London, England. 

Zweifel, Prof., Leipzig, Germany. 

AMERICA AND WEST INDIES. 
Bittencourt, Dr. J. C, Rio Janeiro, Brazil. 
Cooper, Dr. Austin N., Buenos Ayres, Argen- 
tine Republic. 
Dagnino, Prof. Manuel, Caracas, Venezuela. 
Desvernine, Dr. C. M., Havana, Cuba. 
Fernandez, Dr. J. L., Havana, Cuba. 
Finlay, Dr. Charles, Havana, Cuba. 
Fontecha, Prof. R., Tegucigalpa, Honduras. 
Harvey, Dr. Eldon, Hamilton, Bermuda. 
Herdocia, Dr. E. Leon, Nicaragua. 
Levi, Dr. Joseph, Colon, U. S. Columbia. 
Mello. Dr. Vierra de, Rio Janeiro, Brazil. 
Moir, Dr. J. W., Belize, British Honduras. 
Moncorvo, Prof., Rio Janeiro, Brazil. 
Pla, Dr. E. F.. Havana, Cuba. 
Rake, Dr. Beaven, Trinidad. 
Rincon, Dr. F.. Marpc^i^o. Venezuela. 
Semeleder, Dr. F., Mexico, Mexico. 
Soriano, Dr. M. S., Mexico, Mexico. 
Strachan, Dr. Henry, Kingston, Jamaica. 

OCEANICA, AFRICA, AND ASIA. 
Baelz, Prof. R., Tokyo, Japan. 
Barrett, Dr. Jas. W., Melbourne, Australia. 
Branfoot, Dr. A. M., Madias, India. 
Carageorgiades, Dr. J. G, Limassol, Cyprus. 
Cochran, Dr. Joseph P., Oroomiah, Persia. 
Coltman, Dr. Robert, Jr., Che-foo, China. 
Condict, Dr. Alice W., Bombay, India. 
Creece, Dr. John M., Svdnev. Australia. 
Dalzell, Dr. J.. Umsiga, Natal. 
Diamantopulos, Dr. Geo., Smyrna, Turkey. 
Drake-Brockman, Dr., Madras, India. 
Fitzgerald, Mr. T. N., Melbourne. Australia. 
Foreman, Dr. L., Sydney, Australia. 
Gaidzagian. Dr. Oban, Adana, Asia Minor. 
Grant. Dr. David, Melbourne. Australia. 
Johnson, Dr. K., Dera Ishmail Khan. Beloo- 

chistan. 
Kimura, 1'rof. J. K., Tokyo, Japan. 
Knaggs, Dr. 8.. Sydney, Australia. 
Mana-sseh. Dr. Beshara [., Brummana, Turkey 

in Asia. 
McCandless. Dr. II. II. Hainan. China. 
Moloney, Dr. J., Melbourne, Australia. 
Neve, Dr. Arthur. Bombay, India. 
Perez, Dr. George V., Puerto Orotava, Tene- 

rill'e. 
Reid, Dr. John. Melbourne, Australia. 
Robertson. Iir. W. S.. Port Said, Egypt. 
Rouvier, Prof. Jules, Beyrouth, Syria. 
Scranton, Dr. William B., Seoul Corea. 
Sinclair, Dr. II.. Sydney, Australia. 
Thompson. Dr. James B . Petcbaburee, Slam. 
Wheeler, Dr. P.d'E., Jerusalem. Palestine. 

Whitney, I>r. II. T., Foochow, China. 

Whitney, Dr. W. Norton, Tokyo, Japan. 



(29) 



Medical Publications of The F. A. Davis Co., Philadelphia. 
RAWJVEY 

Lectures on Nervous Diseases. 

From the Stand-Point op Cerebral and Spinal Localization, anu 

the Later Methods Employed in the Diagnosis and 

Treatment of these Affections. 

By Ambrose L. Ranney, A.M., M.D., Professor of the Anatomy and 
Physiology of the Nervous System in the New York Post-Graduate 
Medical School and Hospital ; Professor of Nervous and Mental Diseases 
in the Medical Department of the University of Vermont, etc. ; Author 
of "The Applied Anatomy of the Nervous System," " Practical Medical 
Anatomy," etc., etc. 

It is now generally conceded that the nervous S} r stem controls all 
of the physical functions to a greater or less extent, and also that most 
of the symptoms encountered at the bedside can be explained and 
interpreted from the stand-point of nervous physiology. 

Profusely illustrated with original diagrams and sketches in color 
by the author, carefully selected wood-engravings, and reproduced photo- 
graphs of typical cases. One handsome royal octavo volume of 780 pages. 

SOLD ONLY BY SUBSCRIPTION, OR SENT DIRECT ON RECEIPT OF PRICE, 
SHIPPING EXPENSES PREPAID. 

Price, in United States, Cloth, $550; Sheep, $6.50; Half-Bussia, $7.00. 
Canada (duty paid), Cloth, $6.05; Sheep, $7.15 ; Half-Bussia, $7.70. 
Great Britain, Cloth, 32s. ; Sheep, 37s. 6d. ; Half-Bussia, 40s. France, 
Cloth, 34 fr. 70; Sheep, 40 fr. 45 ; Half-Bussia, 43 fr. 30. 

We are glad to note that Dr. Ranney has || sented in compact form, and thus made easily 

published in book form his admirable lectures n accessible. In our opinion, Dr. Ranney's book 

on nervous diseases. His book contains over I ought to meet with a cordial reception at the 

seven hundred large pages, and is profusely I' hands of the medicat profession, for, ewen 

illustrated with original diagrams and sketches though the author's views maybe sometimes 

in colors, and with many carefully selected j open to question, it cannot be disputed that 

wood-cuts and reproduced photographs of '' his work bears evidence of scientific method 

typical tascs. A large amount of valuable i: and honest opinion.— American Journal of 

information, not a little of which has but ' Insanity. 

recently appeared in medical literature, is pre- !| 



STANTON'S 

Practical and Scientific Physiognomy; 

OR 

I*EL~o-w to P5.e;a-cL Faces, 

By Mary Olmsted Stanton. Copiously illustrated. Two large 
Octavo volumes. 

The author, Mrs. Mary 0. Stanton, has given over twent}' years to 
the preparation of this work. Her style is easy, and, by her happy 
method of illustration of every point, the book reads like a novel and 
memorizes itself. To physicians the diagnostic information conveyed is 
invaluable. To the general reader each page opens a new train of ideas. 
(This book has no reference whatever to phrenology.'! 

SOLD ONLY BY SUBSCRIPTION, OR SENT DIRECT ON RECEIPT OF PRICE, 
SHIPPING EXPENSES PREPAID. 

Price, in United States, Cloth, $9.00 ; Sheep, $11.00 ; Half-Bussia, $13.00. 
Canada (duty paid), Cloth, $10.00; Sheep, $12.10; Half-Bussia, 
$14.30. Great Britain, Cloth, 56s. ; Sheep, 68s. ; Half-Bussia, 80s. 
Prance, Cloth, 30 fr. 30 ; Sheep, 36 fr. 40 ; Half-Bussia, 43 fr. 30. 

(30) 



Medical Publications of The F. A. Davis Co., Philadelphia. 
S A JO US 

Lectures on the Diseases of the Nose 
and Throat. 

Delivered at the Jefferson Medical College, Philadelphia. 

By Charles E. Sajous, M.D., Formerly Lecturer on Rhinology and 
Laryngology in Jefferson Medical College; Chief Editor of the Annual of the 
Universal Medical Sciences, etc., etc. 

WW Since the publisher brought this valuable work before the profession, it 
has become : 1st, the text-book of a large number of colleges ; 2d, the reference-booh 
of the IT. S. Army, Navy, and the Marine Service; and, 3d, cm important and 
valued addition to the libraries of over 12,000 physicians. 

This hook has not only the inherent merit of presenting a clear expose of 
the subject, but it is written with a view to enable the general practitioner to 
treat his cases himself. To facilitate diagnosis, colored plates are introduced, 
showing the appearance of the different parts in the diseased state as they appear 
in nature by artificial light. No error can thus be made, as each affection of the 
nose aad throat has its representative in the 100 chromo -lithographs presented. In 
the matter of treatment, the indications are so complete that even the slightest 
procedures, folding of cotton for the forceps, the_ use of the probe, etc., are 
clearly explained. 

Illustrated with 100 chromolithographs, from oil paintings by the author, 
and 93 engravings on wood. One handsome royal octavo volume. 

SOLD ONLY BY SUBSCRIPTION, OR SENT DIRECT ON RECEIPT OF PRICE, 
SHIPPING EXPENSES PREPAID. 

Price, in United States, Cloth, Royal Octavo, $1.00; Half-Russia, Royal 
Octavo, $5.00. Canada (duty paid), Cloth, $140; Half-Russia, $5.50. 
Great Britain, Cloth, 22s. 6d. ; Sheep or Half-Russia, 28s. Prance, 
Cloth, 24 fr. 60 ; Half-Russia, 30 fr. 30. 



It is intended to furnisli the general practi- 
tioner not only with a guide for the treatment 
of diseases of the nose and throat, but also to 
place before him a representation of the nor- 
mal and diseased parts as they would appear 



to him were they seen in the living subject. 
As a guide to the treatment of the nose and 
throat, we can cordially recommend this work. 
— Boston Medical and Surgical Journal. 



IMPORTANT ANNOUNCEMENT. IN PREPARATION. 

PSYCHOPATHIA SEXUALIS: With Especial Reference to Contrary 
Sexual Instinct. 

By Dr. R. von Krafft-Ebing, Professor of Psychiatry and Neurology 
in the University of Vienna. Authorized translation of the Seventh German 
Edition by Chables Gibbkrt Chaddock, M.D , Assistant Medical Superin- 
tendent Northern Michigan Asylum ; Fellow of the Chicago Academy of 
Medicine. 

Prof, von Krafft-Bbing's study of the Psychopathology of the sexual life 
was, when first published, a small monograph; hut in the Beven editions 

through which it has passed so rapidly it has received so many additions and 
been made to cover so completely every aspect of the anomalies of the sexual 
sphere that the work now deserves the name of a treatise. It easily supersedes 
all previous attempts to treat this important subject scientifically, and it is 
sure to commend itself to members of the medical and legal professions as a 
scientific explanation of many social and criminal enigmas to which no work 
in English offers a solution. 

The work trill be sold only by Subscription to Members of the Medical and 
Legal l*rt>fessi<nis. 

(31) 



Medical Publications of The F. A. Davis Co., Philadelphia. 

In Press and in Preparation. 



AUTO-INTOXICATION : Self-Poisoning of the Individual. 

Being a series of lectures on Intestinal and Urinary Pathology. By Prof. 
Bouchard, Paris. Translated from the French with an Original Appendix. 
By Thomas Oliver, M.D., Professor of Physiology, University of Durham, 
England. In one 12mo volume. In Press. 

DISEASES OF THE LUNGS, HEART, AND KIDNEYS. 

By N. S. Davis, Jr., A.M., M.D., Professor of Principles and Practice of 
Medicine, Chicago Medical College; Physician to Mercy Hospital, Chicago; 
Member of the American Medical Association, etc., etc. In one neat 12mo 
volume. No. in the Physicians' and Students' Ready -Reference Series. 
In Press. 

TUBERCULOSIS OF THE BONES AND JOINTS. 

By N. Senn, M.D., Ph.D., Professor of Practice of Surgery and Clinical 
Surgery in Rush Medical College, Chicago, 111.; Professor of Surgery in the 
Chicago Polyclinic ; Attending Surgeon to the Milwaukee Hospital ; Con- 
sulting Surgeon to the Milwaukee County Hospital and to the Milwaukee 
County Insane Asylum ; author of a text-book on the " Principles of Surgery," 
etc., etc. In one handsome Royal Octavo volume. Illustrated with upwards 
of one hundred (100) engravings. In Press. 

A PRACTICE OF SURGERY. 

By John H. Packard, A.M., M.D , Surgeon to the Pennsylvania Hospital 
and to St. Joseph's Hospital, Philadelphia ; Member of the American Surgical 
Association and of the American Medical Association ; formerly Acting 
Assistant Surgeon U. S. Army (1861-65), etc., etc. In one large Royal 
Octavo volume. Handsomely illustrated. In Preparation. 

PRACTICAL GYN/ECOLOGY. 

By E. E. Montgomery, A.M., M.D., Professor of Clinical Gynaecology 
in the Jefferson Medical College, Philadelphia ; Obstetrician to the Phila- 
delphia Hospital ; Gynaecologist to the St. Joseph Hospital ; Fellow and 
ex-President of the American Association of Obstetricians and Gynaecologists, 
etc., etc. In one handsome Royal Octavo volume. Thoroughly and beauti- 
fully illustrated. In Preparation. 

CHILDBED: ITS MANAGEMENT; DISEASES AND THEIR TREAT- 
MENT. 

By Walter P. Manton, M.D., Visiting Physician to the Detroit Woman's 
Hospital ; Consulting Gynaecologist to the Eastern Michigan Asylum ; Presi- 
dent of the Detroit Gymecological Society ; Fellow of the American Society 
of Obstetricians and Gynaecologists and of the British Gynaecological Society; 
Member of Michigan State Medical Society, etc. In one neat 12mo volume. 
In Preparation. 

SYPHILIS IN THE MIDDLE AGES and SYPHILIS IN MODERN TIMES. 

Being Volumes H and III of a treatise on " Syphilis To-Day and Among 
the Ancients." By Dr. F. Buret, of Paris. Translated from the French 
with notes, by A. H. Ohmann-Dumesnil, M.D., Professor of Dermatology 
and Syphilology in the St. Louis College of Physicians and Surgeons; Con- 
sulting Dermatologist to the St. Louis City Hospital; Physician for Cutaneous 
Diseases to the Alexian Brothers' Hospital, etc., etc. 'Each volume 12mo, 
Cloth. To be issued in the Physicians' and Students' Ready-Reference 
Series. In Preparation. 

(32) 









[%£ 



. 








-.r- 








KS 











LIBRARY OF CONGRESS « 



029 827 970 8 




